Exam (elaborations) NURS 1102 PASSPOINT INTEGUMENTARY

NURS 1102 PASSPOINT INTEGUMENTARY Question 1 See full question When assessing a client who is incontinent for risk for developing a pressure ulcer, the nurse should note which factor that can most alter tissue tolerance and lead to the development of a pressure ulcer? You Selected:  exposure to moisture Correct response:  exposure to moisture Explanation: Remediation: Question 2 See full question The nurse is assessing a hospitalized older client for the presence of pressure ulcers. The nurse notes that the client has a 1 inch × 1 inch (3 cm x 3 cm) area on the sacrum in which there is skin breakdown as far as the dermis. What should the nurse note on the medical record? You Selected:  stage I pressure ulcer Correct response:  stage II pressure ulcer Explanation: Remediation: Question 3 See full question Which factor is most important for the nurse to consider when determining the angle at which to insert the needle for a subcutaneous injection? You Selected:  length of the needle Correct response:  amount of subcutaneous tissue Explanation: Remediation: Question 4 See full question During the first 48 to 72 hours of fluid resuscitation therapy after a major burn injury, the nurse should monitor hourly which information that will be used to determine the IV infusion rate? NURS 1102 PASSPOINT INTEGUMENTARY You Selected:  urine output Correct response:  urine output Explanation: Remediation: Question 5 See full question A nurse is preparing a discharge teaching plan for a client with atopic dermatitis. Which instruction should the nurse include in her teaching plan? You Selected:  Use a topical skin moisturizer daily. Correct response:  Use a topical skin moisturizer daily. Explanation: Remediation: Question 6 See full question A client with deep partial-thickness and full-thickness burns on the arms receives autografts. Two days later, the nurse finds the client doing arm exercises. The nurse provides additional client teaching because these exercises may: You Selected:  dislodge the autografts. Correct response:  dislodge the autografts. Explanation: Remediation: Question 7 See full question A client has partial-thickness burns on both lower extremities and portions of the trunk. Which I.V. fluid does the nurse plan to administer first? You Selected:  Lactated Ringer's solution Correct response:  Lactated Ringer's solution Explanation: Remediation: Question 8 See full question The nurse is caring for an immune compromised client with a fungal infection of the scalp. What recommendation should the nurse make to prevent future problems? You Selected:  Wash hair with a dandruff-preventing shampoo. Correct response:  Avoid sharing combs and brushes. Explanation: Remediation: Question 9 See full question A client has suffered a deep partial-thickness burn to the right arm from a high-voltage source of energy that was not turned off while working on it. What is the priority nursing intervention in the acute phase of care? You Selected:  A cardiac monitor should be used for at least 24 hours to anticipate the potential for cardiac dysrhythmias. Correct response:  A cardiac monitor should be used for at least 24 hours to anticipate the potential for cardiac dysrhythmias. Explanation: Remediation: Question 10 See full question A client in a semiprivate room is diagnosed with pediculosis corpus. A nurse will initiate treatment after moving the client to another room. The client's roommate asks the nurse for information about the client. What should the nurse say? You Selected:  "I'm sorry, but I can't share confidential information." Correct response:  "I'm sorry, but I can't share confidential information." Question 1 See full question A female client is diagnosed with primary herpes genitalis. Which instruction should the nurse provide? You Selected:  "Apply acyclovir ointment to the lesions every 3 hours, six times per day for 7 days." Correct response:  "Apply acyclovir ointment to the lesions every 3 hours, six times per day for 7 days." Explanation: Remediation: Question 2 See full question A client who was bitten by a wild animal is admitted to an acute care facility for treatment of rabies. Which type of isolation does this client require? You Selected:  Contact Correct response:  Contact Explanation: Remediation: Question 3 See full question Which instruction is the most important to give a client who has recently had a skin graft? You Selected:  Protect the graft from direct sunlight. Correct response:  Protect the graft from direct sunlight. Explanation: Remediation: Question 4 See full question An occupational nurse is called to treat an employee who experienced a finger injury on a piece of equipment. When the nurse arrives, it is discovered that the finger tip was cut off at the first digit and is bleeding profusely. What should be the nurse's first action? You Selected:  Apply pressure to the radial artery of that extremity to decrease bleeding. Correct response:  Apply direct pressure to the finger with a clean, dry cloth. Explanation: Remediation: Question 5 See full question A nursing assistant tells the nurse that a client with paraplegia has an area of skin breakdown on his left calf. When the nurse assesses the client, he is sitting on a cushion in a wheelchair and wearing specialty boots. The nurse notes a circular wound 2 cm × 2 cm × 0.25 cm on the posterior aspect of the calf. What most likely caused the client's skin breakdown? You Selected:  Sitting in the wheelchair for long periods of time Correct response:  Specialty boots Explanation: Remediation: Question 6 See full question A client has a wound on the ankle that is not healing. The nurse should assess the client for which risk factors for delayed wound healing? Select all that apply. You Selected:  type 2 diabetes mellitus  hypertension  advancing age Correct response:  advancing age  type 2 diabetes mellitus  smoking Explanation: Remediation: Question 7 See full question The nurse is aware that, in addition to the rule of nines, which is the most important assessment priority when assessing a client with facial burns? You Selected:  Checking for airway patency Correct response:  Checking for airway patency Explanation: Remediation: Question 8 See full question A client reports a firm, red nodule with a scaly crust on his back. Which of the following is the best nursing intervention? You Selected:  Notify the healthcare provider. Correct response:  Notify the healthcare provider. Explanation: Remediation: Question 9 See full question A client with partial thickness burns to the chest and shoulders 6 hours after a fire has become restless and confused. Which of the following actions action should the nurse take? You Selected:  Assess oxygen saturation using pulse oximetry Correct response:  Assess oxygen saturation using pulse oximetry Explanation: Remediation: Question 10 See full question The registered nurse (RN) is referred to a client’s home when a husband and wife have been confirmed to have scabies. The family asks, “How will we get rid of this?” When instructing on the proper procedure to wash contaminated clothing and sheets, which nursing instruction is a priority? You Selected:  Use hot water throughout wash cycle. Correct response:  Use hot water throughout wash cycle. Question 1 See full question The physician orders "acyclovir, 200 mg P.O., every 4 hours while awake" for a client with herpes zoster. The nurse should inform the client that this drug may cause: You Selected:  diarrhea. Correct response:  diarrhea. Explanation: Remediation: Question 2 See full question A client arrives at the emergency department after falling in the home. The nurse performing the assessment notes the presence of pediculosis corpus. The client's skin and clothing are dirty. The client reports that his children work and no one has time to assist him with his self-care activities. The nurse should: You Selected:  Advise the family of the client's accusations. Correct response:  Contact the nursing supervisor. Explanation: Remediation: Question 3 See full question The client with a major burn injury receives total parenteral nutrition (TPN). The expected outcome is to: You Selected:  ensure adequate caloric and protein intake. Correct response:  ensure adequate caloric and protein intake. Explanation: Remediation: Question 4 See full question A nurse is providing education in a community setting about general measures to avoid excessive sun exposure. Which recommendation is appropriate? You Selected:  Apply sunscreen with a sun protection factor (SPF) of 30 or more before sun exposure. Correct response:  Apply sunscreen with a sun protection factor (SPF) of 30 or more before sun exposure. Explanation: Remediation: Question 5 See full question To treat a client with acne vulgaris, the physician is most likely to order which topical agent for nightly application? You Selected:  Tretinoin Correct response:  Tretinoin Explanation: Remediation: Question 6 See full question Which disciplines should be consulted when caring for a client with a stage III heel ulcer? You Selected:  Occupational therapy and infectious disease Correct response:  Nutrition support and orthotics Explanation: Remediation: Question 7 See full question Which factor would have the least influence on the survival