Medical Surgical Nursing 8th Edition by
Ignatavicius Test Bank 2025
The client has dry skin and a history of cardiovascular disease. Which is
the best intervention for the nurse to teach the client? a. "Wear pajamas
to cover your legs at night."
b. "Avoid wearing stockings."
c. "Increase your fluid intake to 3 L/day."
d. "Bathe in warm water and then apply lotion immediately." -
ANSWER>>ANS: D
The client should bathe in warm water for at least 20 minutes and then
apply lotion immediately because this will keep the moisture in the skin.
Covering the legs at night will not increase moisture. Increasing fluid intake
to 3 L/day would not be recommended for a client with a history of
cardiovascular disease. Stockings may dry the skin, so the best
intervention is to keep moisture in the skin with lotion.
Which intervention will best assist the client with pruritus?
a. "Avoid activities and environments that increase perspiration."
b. "Drinking alcoholic beverages will decrease stimulation of the itch
receptors."
c. "Wear clothing to keep the skin warm."
d. "Avoid immersing the affected areas in water." - ANSWER>>ANS: A
Pruritus is exacerbated by poor skin hydration, increased skin
temperature, perspiration, and vasodilation. Drinking alcoholic beverages
will further dehydrate clients. Warm clothing will vasodilate, adding to
dehydration. Warm baths are recommended, with lotion applied
immediately afterward.
Which precaution will the nurse teach the client with urticaria who is
prescribed to take diphenhydramine (Benadryl)? a. "Avoid sun
exposure."
b. "Avoid alcoholic beverages."
c. "Avoid aspirin or aspirin-containing drugs."
,d. "Avoid weight gain." - ANSWER>>ANS: B
Benadryl is an antihistamine that will decrease itching. For most people,
diphenhydramine causes drowsiness. This side effect is intensified when
alcohol also is consumed, placing the client at increased risk for injury and
falling. Aspirin will not interact with this medication. Weight gain and sun
exposure should not affect the administration of the drug.
When changing the dressing on a partial-thickness wound, a nurse
observes small, pale pink bumps within the wound bed. Which is the
nurse's best action?
a. Removing the bumps with a sterile scalpel
b. Documenting and continuing current treatment
c. Cleaning the wound vigorously, wiping off the bumps
d. Culturing the wound and placing the client on contact precautions -
ANSWER>>ANS: B
The small, pale pink bumps are granulation tissue characteristic of new
capillary bed growth, an indication of proper wound healing. The nurse
should continue current treatment and assessments. Attempting to remove
the bumps in any way can interfere with healing.
Which nursing intervention is best for the nurse to use to enhance healing
of a 1-week-old partial-thickness wound?
a. Using papain-urea (Accuzyme) cream as ordered
b. Restricting the client's fluid intake
c. Covering the wound with an airtight dressing
d. Applying hydrocortisone cream as ordered - ANSWER>>ANS: A
The presence of necrotic tissue retards epithelialization and granulation
development. Accuzyme is a cream that removes necrotic tissue.
Restricting fluid and covering the wound will deprive the new tissue of
nutrition and will not enhance healing. Hydrocortisone cream may decrease
itching but will not enhance healing.
Which is the priority nursing diagnosis for the client going home with a
surgical wound on the coccyx that is to heal by second intention? a.
Acute Pain
, b. Risk for Infection
c. Disturbed Body Image
d. Risk for Deficient Fluid Volume - ANSWER>>ANS: B
Any wound left to heal by second intention is an open wound and is at risk
for infection. Usually, within 2 days after the surgery, discomfort is minimal
and the wound is not draining sufficiently for the client's fluid balance to be
deficient. The client could have a disturbed body image in this situation,
although wounds on the coccyx are not visible to the public. However, the
priority in this situation is to prevent infection.
Which nursing intervention will best assist a client who is bedridden to keep
skin intact?
a. Keeping the skin dry
b. Repositioning the client every 2 hours
c. Using a foam mattress pad
d. Using a lift sheet to move the client up in bed - ANSWER>>ANS: D
Friction forces are generated when the client is dragged or pulled across
bed linen. Using a lift sheet will prevent friction. Keeping the skin dry will
not keep skin intact. Research actually recommends turning the client
every 20 minutes to minimize vasoconstriction from dependency. A foam
mattress will not significantly decrease pressure to an area.
A nurse determines a client as having a Braden scale score of 9. Which is
the nurse's best intervention related to this assessment?
a. Encouraging the client to lay as still as possible in bed
b. Reassessing the client weekly
c. Increasing the client's fluid intake daily
d. Consulting with the health care provider about increased interventions -
ANSWER>>ANS: D
A score of 11 or less on the Braden scale indicates severe risk for pressure
ulcer development in terms of decreased sensory perception, exposure to
moisture, decreased independent activity, decreased mobility, poor
nutrition, and chronic exposure to friction and shear.
Ignatavicius Test Bank 2025
The client has dry skin and a history of cardiovascular disease. Which is
the best intervention for the nurse to teach the client? a. "Wear pajamas
to cover your legs at night."
b. "Avoid wearing stockings."
c. "Increase your fluid intake to 3 L/day."
d. "Bathe in warm water and then apply lotion immediately." -
ANSWER>>ANS: D
The client should bathe in warm water for at least 20 minutes and then
apply lotion immediately because this will keep the moisture in the skin.
Covering the legs at night will not increase moisture. Increasing fluid intake
to 3 L/day would not be recommended for a client with a history of
cardiovascular disease. Stockings may dry the skin, so the best
intervention is to keep moisture in the skin with lotion.
Which intervention will best assist the client with pruritus?
a. "Avoid activities and environments that increase perspiration."
b. "Drinking alcoholic beverages will decrease stimulation of the itch
receptors."
c. "Wear clothing to keep the skin warm."
d. "Avoid immersing the affected areas in water." - ANSWER>>ANS: A
Pruritus is exacerbated by poor skin hydration, increased skin
temperature, perspiration, and vasodilation. Drinking alcoholic beverages
will further dehydrate clients. Warm clothing will vasodilate, adding to
dehydration. Warm baths are recommended, with lotion applied
immediately afterward.
Which precaution will the nurse teach the client with urticaria who is
prescribed to take diphenhydramine (Benadryl)? a. "Avoid sun
exposure."
b. "Avoid alcoholic beverages."
c. "Avoid aspirin or aspirin-containing drugs."
,d. "Avoid weight gain." - ANSWER>>ANS: B
Benadryl is an antihistamine that will decrease itching. For most people,
diphenhydramine causes drowsiness. This side effect is intensified when
alcohol also is consumed, placing the client at increased risk for injury and
falling. Aspirin will not interact with this medication. Weight gain and sun
exposure should not affect the administration of the drug.
When changing the dressing on a partial-thickness wound, a nurse
observes small, pale pink bumps within the wound bed. Which is the
nurse's best action?
a. Removing the bumps with a sterile scalpel
b. Documenting and continuing current treatment
c. Cleaning the wound vigorously, wiping off the bumps
d. Culturing the wound and placing the client on contact precautions -
ANSWER>>ANS: B
The small, pale pink bumps are granulation tissue characteristic of new
capillary bed growth, an indication of proper wound healing. The nurse
should continue current treatment and assessments. Attempting to remove
the bumps in any way can interfere with healing.
Which nursing intervention is best for the nurse to use to enhance healing
of a 1-week-old partial-thickness wound?
a. Using papain-urea (Accuzyme) cream as ordered
b. Restricting the client's fluid intake
c. Covering the wound with an airtight dressing
d. Applying hydrocortisone cream as ordered - ANSWER>>ANS: A
The presence of necrotic tissue retards epithelialization and granulation
development. Accuzyme is a cream that removes necrotic tissue.
Restricting fluid and covering the wound will deprive the new tissue of
nutrition and will not enhance healing. Hydrocortisone cream may decrease
itching but will not enhance healing.
Which is the priority nursing diagnosis for the client going home with a
surgical wound on the coccyx that is to heal by second intention? a.
Acute Pain
, b. Risk for Infection
c. Disturbed Body Image
d. Risk for Deficient Fluid Volume - ANSWER>>ANS: B
Any wound left to heal by second intention is an open wound and is at risk
for infection. Usually, within 2 days after the surgery, discomfort is minimal
and the wound is not draining sufficiently for the client's fluid balance to be
deficient. The client could have a disturbed body image in this situation,
although wounds on the coccyx are not visible to the public. However, the
priority in this situation is to prevent infection.
Which nursing intervention will best assist a client who is bedridden to keep
skin intact?
a. Keeping the skin dry
b. Repositioning the client every 2 hours
c. Using a foam mattress pad
d. Using a lift sheet to move the client up in bed - ANSWER>>ANS: D
Friction forces are generated when the client is dragged or pulled across
bed linen. Using a lift sheet will prevent friction. Keeping the skin dry will
not keep skin intact. Research actually recommends turning the client
every 20 minutes to minimize vasoconstriction from dependency. A foam
mattress will not significantly decrease pressure to an area.
A nurse determines a client as having a Braden scale score of 9. Which is
the nurse's best intervention related to this assessment?
a. Encouraging the client to lay as still as possible in bed
b. Reassessing the client weekly
c. Increasing the client's fluid intake daily
d. Consulting with the health care provider about increased interventions -
ANSWER>>ANS: D
A score of 11 or less on the Braden scale indicates severe risk for pressure
ulcer development in terms of decreased sensory perception, exposure to
moisture, decreased independent activity, decreased mobility, poor
nutrition, and chronic exposure to friction and shear.
