RN Integumentary System EAQ EXAM Latest Version

RN Integumentary System EAQ EXAM What could be the possible cause of a scald injury? Contact with grease Contact with hot liquids or steam Contact with alkali in oven cleaners Contact with open flame in house fires Which complication may be caused by sepsis in burns? Diarrhea Constipation Paralytic ileus Curling’s ulcer What is a clinical manifestation of hypernatremia in burns? Fatigue Seizures Paresthesias Cardiac dysrhythmias The nurse is teaching the client about wound healing. Which feature is associated with the "maturation phase" of normal wound healing? The scar is firm and inelastic on palpation. Fibrin strands form a scaffold or framework. White blood cells migrate into the wound. Epithelial cells are grown over the granulation tissue bed. which key feature does the nurse associate with a stage 2 pressure ulcer? Presence of nonintact skin Development of sinus tracts Damage to the subcutaneous tissues Appearance of a reddened area over a bony prominence Which type of biopsy would the nurse identify as required for removal of entire lesions on the skin? Punch biopsy Shave biopsy Incisional biopsy Excisional biopsy Which test would the client undergo to receive a diagnosis of systemic lupus erythematosus? Patch test Photo patch test Direct immunofluorescence testIndirect immunofluorescence test Which benign condition of the client’s skin is associated with the grouping of normal cells derived from melanocyte-like precursor cells? Nevi Psoriasis Acne vulgaris Plantar warts Which type of allergic skin condition in a client is associated with immunological irregularity, asthma, and allergic rhinitis? Urticaria Psoriasis Acne vulgaris Atopic dermatitis Which does the nurse understand related to negative pressure wound therapy? Select all that apply. Using a suction pump Treating necrotizing infections Administering oxygen under high pressure Application of a low-voltage current to a wound area Reducing chronic ulcers by removing fluids from the wound Which clinical manifestation is associated with cellulitis? Lymphadenopathy Occasional papules Vesicles that evolve into pustules Isolated erythematous pustules Which surgery is used to treat excessive wrinkling or sagging of facial skin? Rhinoplasty Rhytidectomy Dermabrasion Blepharoplasty Which skin infection would cause facial paralysis? Herpes zoster Herpes simplex DermatophytosisWhich secondary skin lesion may include athlete’s foot as an example? Scar Scale Ulcer Fissure Which component of skin maintains optimal barrier function? Keratin Melanin Collagen Adipose tissue A nurse is caring for a client with scabies. Which information about scabies should the nurse consider when planning care for this client? Highly contagious Caused by a fungus Chronic with exacerbations Associated with other allergies Which drug is a newer treatment option for treating metastatic melanoma? Lomustin Ipilimumab Carmustine Temozolomide A client is scheduled for radiation treatments Monday through Friday. The client asks why the treatments will not be given on Saturday and Sunday. Which is the nurse’s best response? "This type of schedule gives noncancerous cells time to recover." "The department only operates from Monday through Friday." "Your energy level will be increased greatly by a 5-day schedule." "Side effects are eliminated when treatment is administered for 5 rather than 7 days." Which clinical finding occurs due to thinning of the subcutaneous layer? Decreased tone and elasticity Decreased sensory perception Increased risk for hypothermia Increased susceptibility to dry skin The nurse is caring for a client who has been bitten by a raccoon. The client states, "Where I live, there seems to be raccoons and wild animals everywhere." Which information should the nurse consider about rabies when planning care for this client? Rabies is a bacterial infection characterized by encephalopathy and opisthotonos.Rabies is an acute bacterial septicemia that results in convulsions and a morbid fear of water. Rabies is a nonspecific immune response to organisms deposited under the skin by an animal bite. Rabies is an acute viral infection, characterized by convulsions and difficulty swallowing, that affects the nervous system. A nurse is caring for a client with quadriplegia. Which nursing intervention will decrease the occurrence of pressure ulcers? Avoiding leg massages Frequent repositioning of client Increasing fiber content in food Encouraging weight-bearing exercises What is an example of third spacing in a burn injury? Blister formation Edema formation Fluid mobilization Fluid accumulation A client is admitted to the hospital with partial- and full-thickness burns of the chest and face sustained while trying to extinguish a brush fire. Which is the nurse’s priority concern? Loss of skin integrity caused by the burns Potential infection as a result of the burn injury Inadequate gas exchange caused by smoke inhalation Decreased fluid volume because of the depth of the burns Which clinical manifestation is characterized by eczematous eruption with well-defined geometric margins? Drug eruption Atopic dermatitis Contact dermatitis Nonspecific eczematous dermatit Which drug can cause chemical burns? Anthralin Prednisone Tazarotene Calcipotriene Which infection is caused due to fungus?Furuncle Folliculitis Herpes zoster Dermatophytosis Which condition is an example of a bacterial infection? Impetigo Candidiasis Plantar warts Verucca vulgaris During the first 48 hours after a client has sustained a thermal injury, which conditions should the nurse assess for? Hypokalemia and hyponatremia Hyperkalemia and hyponatremia Hypokalemia and hypernatremia Hyperkalemia and hypernatremia How would the nurse describe the exudate characteristic of a serosanguineous wound? Greenish-blue pus Creamy yellow pus Blood-tinged amber fluid Beige pus with a fishy odor The nurse is caring for a client with a diagnosis of necrotizing fasciitis. Which is the priority concern of the nurse when caring for this client? Fluid volume Skin integrity Physical mobility Urinary elimination Which type of laser is used in the treatment of vascular and other pigmented lesions? Argon Gold vapors Neodymium Carbon dioxide What are the side effects of oral psoralen in phototherapy? Select all that apply. Atrophy Sunburn MucositisOccular damage Persistent pruritus A nurse is caring for a client with severe burns. The nurse determines that this client is at risk for hypovolemic shock. Which physiologic finding supports the nurse’s conclusion? Decreased rate of glomerular filtration Excessive blood loss through the burned tissues Plasma proteins moving out of the intravascular compartment Sodium retention occurring as a result of the aldosterone mechanism Which benign condition shows silver scaly plaques on the skin? Nevi Psoriasis Urticaria Acne vulgaris The nurse is teaching campfire safety to a group of community members and includes information about what to do if a person catches on fire. The nurse teaches the most effective method for putting out the flames. Which information from the group members indicates successful learning? Wrap hand with towel and slap at the flames. Instruct the victim to roll on the ground. Pour cold liquid over the flames. Remove the victim’s burning clothes. What is the mechanism of action for wet-to-damp saline-moistened gauze for wound debridement? Promoting the dilution of viscous exudate Removing the necrotic tissue mechanically Causing a breakdown of the denatured protein of eschar Promoting the spontaneous separation of necrotic tissue Which skin color alteration may be observed in a client diagnosed with methemoglobinemia? Red Blue White Yellow-orange Which characteristic does the nurse associate with a punch biopsy? It is usually indicated for superficial or raised lesions. It is more uncomfortable than other biopsies while healing. It is performed using a circular cutting instrument 2 to 6 mm in diameter.It removes only the portion of the skin that rises above the surrounding tissue. Which causative organism colonization signifies purulent exudates of greenish-blue pus with a fruity odor? Proteus Bacteroides Pseudomonas Staphylococcus The nurse is caring for two clients with a below-the-knee amputation. The first client was in a motor vehicle collision. The second client had chronically decreased arterial perfusion. Which information has caused the nurse to conclude that the postoperative courses of these two clients may differ? The first client probably will adjust more quickly. The second client’s incision will take longer to heal. These clients are likely to have very different occupations. The first client is more likely to have phantom limb sensations. Which description is associated with fissures? Deep erosions that extend beneath the epidermis Thinning of the skin surface with a loss of skin markings Linear cracks in the epidermis that extend into the dermis Thickened areas of epidermis with accentuated skin markings Which description describes a coalesced type of skin lesion configuration? Lesions are well defined with sharp borders. Lesions merge together and appear confluent. Lesions are ringlike around flat centers of skin. Lesions have wavy borders that resemble a snake. The nurse is caring for a client with burns and reviews the client’s laboratory results: blood urea nitrogen (BUN), 30 mg/dL (10.2 mmol/L); creatinine, 2.4 mg/dL (184 mcmol/L); serum potassium, 6.3 mEq/L (6.3 mmol/L); pH, 7.1; Po 2, 90 mm Hg; and hemoglobin (Hgb), 7.4 g/dL (74 mmol/L). Which condition does the nurse suspect the client has based upon these findings? Azotemia Hypokalemia Metabolic alkalosis Respiratory alkalosis Which statement by the nurse is true regarding dandruff? "It is a problem of excessive oil production." "It can occur as a side effect of drug therapy.""It is associated with tenderness of the scalp." "It is a manifestation of hormonal imbalance." A client with cellulitis of the leg asks why bed rest has been prescribed to prevent sepsis. Which purpose will the nurse explain to the client? This decreases catabolism to promote healing at the site of injury. This lowers the metabolic rate in an attempt to help reduce the fever. This reduces the energy demands on the body in the presence of infection. This limits muscle contractions that may force causative organisms into the bloodstream. A nurse is caring for a client who experienced serious burns in a fire. Which relationship between a client’s burned body surface area and fluid loss should the nurse consider when evaluating fluid loss in a client with burns? Equal Unrelated Inversely related Directly proportional Which dermatologic problem is treated by using intralesional corticosteroids? Psoriasis Cellulitis Erysipelas Carbuncles What would the nurse state is a cause of systemic altered inflammatory response in impaired wound healing? Uremia Cirrhosis Leukemia Hypovolemia What is the source of an Integra graft? Porcine skin Cadaveric skin Glycosaminoglycan bonded to silicone membrane Porcine collagen bonded to silicone membrane What would the nurse state is a serious side effect of x-rays? Vesicles PapularDesquamation Plaque-like lesions Which fungal infection does the client refer to as jock itch? Tinea pedis Tinea cruris Tinea corporis Tinea unguium Which predisposing condition may be present in a client with pitting edema? Shock Kidney disease Hypothyroidism Severe dehydration A nurse provides discharge teaching to a client who had a total hip replacement. The client states that the plan is to go swimming at the community pool the day after discharge. How should the nurse respond? Instruct the client to take a friend along for safety. Encourage participation in this activity, because it provides excellent range-ofmotion exercise. Explain that the incision should not be immersed in water until it has healed. Let the client know that swimming can substitute for the prescribed physical therapy. A client who is receiving combination chemotherapy for stage II Hodgkin disease is at risk for stomatitis. Which information should the nurse include in the teaching plan? "Rinse the mouth three times a day with lemon juice and water." "Brush the teeth once daily and use dental floss after each meal." "Clean the mouth with a soft toothbrush or a gentle spray." "Gently clean the mouth with commercial mouthwash." A nurse is caring for an older adult who was admitted to the hospital to be treated for dehydration. While the nurse is providing discharge teaching, the client asks what to do about itchy dry skin? What is the best response by the nurse? Wear plenty of warm clothes to keep moisture in the skin. Use a moisturizer on the skin daily to help reduce itching. Take hot tub baths only twice a week to reduce drying of the skin. Expose the skin to the air to help reduce the sensation of itching. A client with a skin infection reports an itching sensation associated with pain at the site of infection. The assessment finding shows erythematous blisters and interdigital scaling and maceration. What could be the possible condition in the client?Tinea pedis Tinea cruris Tinea corporis Tinea unguium A client with the diagnosis of breast cancer is scheduled to receive radiation therapy to the affected area. The nurse teaches the client about how to care for the area that will be irradiated. Which client statement indicates the nurse needs to follow up? "I will leave the skin markings intact." "I will protect the skin from sources of heat." "I will wear soft clothing over the upper body." "I will use an oatmeal-based lotion after each treatment." A burn client is receiving the open method for wound treatment. Which information will the nurse explain to the client? Bathing will not be permitted. Dressings will be changed daily. Personal protective equipment will be worn by staff. Room temperature will be kept below 72° F (22.2° C). What is the color of a client’s wound caused by skin tears? Red Gray Black Yellow While caring for a client with advanced muscular dystrophy who suffered respiratory distress, the nurse frequently repositions the client to prevent the development of pneumonia. Which other complication can be prevented through this nursing intervention? Renal calculi Disorientation Pressure ulcers Urinary infection A 23-year-old client has white hair. Which change in the hair is responsible for this condition? Decreased oils Decreased density Decreased estrogen levels Decreased melanocytes While assessing the skin of a client, the nurse observes a lesion that has a wavy border. Which type of lesion is present in the client?Annular Circinate Coalesced Serpiginous A nurse is developing a teaching plan for a client with lower extremity arterial disease (LEAD). Which information will the nurse include in the teaching plan? Trimming toenails so that they are short and rounded Checking bathwater temperature by putting the toes in first Using alcohol to rub hands, feet, legs, and arms at least two times a day Seeking professional treatment for any minor injuries to the extremities A client is admitted with severe burns. The nurse is caring for the client 36 hours after the client’s admission and identifies the client’s potassium level of 6.0 mEq/L (6.0 mmol/L). Which drink will the nurse recommend be included in the client’s diet? Milk Tea Orange juice Tomato juice Which complications does the nurse anticipate in the client who has blue-colored nail beds? Thrombocytopenia Polycythemia vera Methemoglobinemia Cardiopulmonary disease Which physical changes may cause longitudinal nail ridges? Decreased rate of growth Decreased cell division Decreased blood flow Decreased vitamin D production Which type of allergic condition of the skin manifests in the client as delayed hypersensitivity? Utricaria A drug reaction Atopic dermatitis Allergic contact dermatitis A client who was hospitalized with partial- and full-thickness burns over 30% of the total body surface area is to be discharged. The client asks the nurse, "How will my spouse be able to care for me at home?" How should the nurse interpret this statement? Readiness to discuss the client’s deformitiesIndication of a change in family relations Need for more time to think about the future Beginning realization of implications for the future Which fungal infection in a client is commonly referred to as athlete’s foot? Tinea pedis Tinea cruris Tinea corporis Tinea unguium Which technique would the nurse describe as promoting autolysis in the spontaneous separation of necrotic tissue? Continuous wet gauze Moisture-retentive dressing Topical enzyme preparations -Wet-to-dry damp saline moistened gauz A client sustained minor skin injuries following an accident. Which event occurs close to the time of injury? Thinning of the scar tissue Formation of granulation tissue Migration of leukocytes to the site of injury Arrival of fibroblasts to the site of infection A client who sustained a burn injury involving 36% of the body surface area is receiving hydrotherapy. Which is the best nursing intervention when providing wound care? Use a consistent approach to care and encourage participation. Prepare equipment while doing the procedure and explain the treatment to the client. Rinse the burn area with 105° F (40.6° C) water to prevent loss of body temperature. Arrange for a change of staff every 4 to 5 days and have the client select the time for the procedure to be done. A client was admitted with full-thickness burns 2 weeks ago. Since admission, the client has lost an average of 1 lb (0.5 kg) of weight each day. Which action will the nurse most likely take based upon the adjusted dietary plan? Provide low-sodium milk. Provide high-protein drinks. Provide foods that are low in potassium. Provide 10% more calories in the form of fats. Which condition will the nurse monitor for in a client with interruption of venous return?Tenting Varicosity Petechiae Ecchymosis Which skin damage is caused by chronic exposure to ultraviolet rays? Select all that apply. Dryness Photoaging Vascular lesions Wrinkling of skin Benign neoplasm A burn victim has waxy white areas interspersed with pink and red areas on the anterior trunk and all of both arms. The nurse calculates the percentage of total body surface area (TBSA). Which percentage will the nurse report? 20 25 30 36 A dark-skinned client has a gray-colored tongue and lips. Which complication does the nurse suspect? Cyanosis Jaundice Bleeding Inflammation Which physiologic activity is associated with the "proliferative phase" of normal wound healing? White blood cells migrate into the wound Epithelial cells grow over the granulation tissue bed Scar tissue gradually becomes thinner and pale in color Vasodilation occurs with increased capillary permeability Which practice would be suitable in the prevention of a pressure ulcer? Positioning a client directly on the trochanter Keeping the client’s skin directly off plastic surfaces Keeping the head of the bed elevated above 30 degrees Placing a rubber ring or donut under the client’s sacral area The nurse is providing postoperative care to a client who had an abdominal cholecystectomy and choledochostomy who has a T-tube and a nasogastric tube in place. The client refuses deepbreathing and coughing exercises. Which conclusion by the nurse is the most probable reason for the noncompliance? T-tube movement increases. Pain at the incision site increases. The nasogastric tube gets irritating. The bandage on the abdomen is constricting. Which integumentary change is associated with delayed wound healing in a client? Decreased cell division Decreased epidermal thickness Decreased immune system cells Increased epidermal permeability Which drug is prescribed for the client to treat severe nodulocystic acne? Imiquimod Isotretinoin Clindamycin Corticosteroids What is the function of the dermis? Provides cells for wound healing Assists in retention of body heat Acts as mechanical shock absorber Inhibits proliferation of microorganisms A nurse places a client with severe burns on a circulating air bed. Which goal is the nurse trying to achieve? Increasing mobility Preventing contractures Limiting orthostatic hypotension Preventing pressure on peripheral blood vessels A male client with ascites is to have a paracentesis and has signed the consent. While the nurse is caring for him, he says that he has changed his mind and no longer wants the procedure. Which initial response by the nurse is best? "Why did you sign the consent?" "Can you tell me why you decided to refuse the procedure?" "You are obviously afraid about something concerning the procedure." "Although the procedure is very important, I understand why you changed your mind."A client with a parotid tumor and enlarged lymph nodes in the neck is undergoing radiation therapy on an outpatient basis. Which condition will the nurse most closely assess the client for during the return visit to the radiology department? Ataxia Hypoxia Arthralgia Dysphagia A nurse is assessing the integumentary system of four clients. Which client has the least chance of a false-positive result while undergoing assessment of capillary refill time? Client with shock Client with anemia Client with epilepsy Client with peripheral vascular disease Which nursing assessment finding is associated with chronic eczema? Localized edema Rough and thick skin Decreased skin turgor Increased skin temperature A nurse is assessing a client with the diagnosis of scleroderma for signs of calcium deposits in organs, Raynaud phenomenon, esophageal dysfunction, sclerodactyly, and telangiectasia (CREST syndrome). Which clinical indicators should the nurse expect to identify upon assessment? Select all that apply. Joint pain Masklike facies Esophageal dysmotility Spiderlike hemangiomas Episodic blanching of the fingers A nurse is about to perform a wound irrigation on a client who had a left hemispheric stroke 1 year ago. Which assessment is most important for the nurse to perform before beginning the irrigation? Neurologic Wound Pain Skin Which gastrointestinal (GI) change may be found in the client with burn injuries? Abdominal distention Increased peristalsisActivation of GI motility Increased blood flow to the GI area The nurse is providing care for a client diagnosed with invasive pancreatic cancer. The client has a permanent biliary drainage tube (T-tube) inserted to provide palliative care. Which action should the nurse take postoperatively? Maintain intermittent low suction to limit trauma. Cleanse the area around the insertion site to prevent skin breakdown. Attach the tube to a negative-pressure drainage system to promote drainage. Reposition the client frequently to increase the flow of bile through the tube. Which finding could be described as visibly dilated, superficial, and cutaneous small blood vessels found on the face and thighs? Tenting Angioma Varicosity Telangiectasia Which description is associated with a hematoma? The occurrence of redness in patches of variable size and shape The thickening of the skin with accentuated normal skin markings The visible swelling due to extravasation of blood of sufficient size The pinpoint, discrete deposits of blood in the extravascular tissues The client reports crumbly, discolored, and thickened toenails. What could be the possible reason for this condition? Allergy Insect bite Fungal infection Bacterial infection In preparation for discharge, a client who had a total hip replacement is taught wound care by the nurse. Which statement from the client indicates a correct understanding of the nurse’s instructions? "I will sit in a chair for several hours every day." "I will inspect the incision for healing when I change the dressing." "I will check to see whether the staples have dissolved within a few days." "I will call the health care clinic if I see any clear drainage coming from the incision." A client reports facial lesions that are surrounded by redness and cause itching. On assessment, the lesions are found to be thick with a honey-colored crust and surrounded by erythema. Which infection is suspected by the primary healthcare provider?Shingles Impetigo Folliculitis Verruca vulgaris What should the nurse teach a client about how to care for the skin around a colostomy stoma? "Wash with soap and water." "Rinse the area with peroxide." "Apply a thick coat of an emollient." "Rub vigorously to remove hardened feces." Which changes to the client’s skin are caused by the atrophy of eccrine sweat glands? Bruises Dry skin Wrinkles Skin shearing A client visited the nurse with a complaint of chalk white patches on the skin. What could be the condition of the client? Vitiligo Jaundice Cyanosis Erythema A client arrives at the emergency department after being bitten by a dog. The bite involved tearing of skin and deep soft tissue injury. Which action should the nurse take first? Inform the owner of the dog about the client’s injury. Assess the client’s injury, vital signs, and past history. Obtain a prescription for human rabies immune globulin. Notify the appropriate community agency to capture the dog. A client is diagnosed with psoriasis, and the nurse is providing health teaching concerning skin care at home. Which recommendation does the nurse include in the teaching? "Shower twice a day." "Soak the affected areas in hot water." "Apply moisturizing lotion several times a day." "Cover affected areas when in contact with others." A nurse is preparing to change a client’s dressing. Which information should the nurse recall for using surgical asepsis? Keep the area free of microorganisms. Protect self from microorganisms in the wound.Confine the microorganisms to the surgical incision site. Limit the number of opportunistic microorganisms to a minimum. Which life-threatening wounds are treated with hyperbaric oxygen therapy? Select all that apply. Burns Skin cancer Osteomyelitis Diabetic ulcers Myocardial infarction What should the nurse consider when providing care to a client in the acute phase of treatment for a full-thickness burn? The risk of septicemia and its potential complications from treatment The risk of psychosocial adjustments and resuming previous roles The risk of oral mucous membrane injury and its associated risks The risk of insufficient community resources and emotional support A client has bright-red erythematosus macules and papules on the skin. What could be the diagnosis? Drug eruption Atopic dermatitis Contact dermatitis Nonspecific eczematous dermatitis Which client has a primary lesion? One with scales One with ulcers One with fissures One with erosions Which organism infestation is diagnosed with the help of the mineral oil test? Lice Ticks Mites Fungus Which skin color in a client indicates an increased urochrome level? Red Blue Reddish blue Yellow-orangeWhich conditions in a client are associated with a bluish color of the mucous membranes? Select all that apply. Edema Diabetes mellitus Hemochromatosis Methemoglobinemia Cardiopulmonary disease While palpating the skin of a client, the nurse observes pitting edema on the dorsum of the foot. What could be the reason for this condition? Endocrine imbalance Excessive collagen production Fluid and electrolyte imbalance Autonomic nervous system stimulation The nurse is caring for a client 4 days after the client was admitted to the hospital with burns on the trunk and arms. The nurse collaborates with the dietician to develop a dietary plan for the following day. Which plan will the nurse follow? High caloric intake, liberal potassium intake, and 3 g protein/kg/day High caloric intake, restricted potassium intake, and 1 g protein/kg/day Moderate caloric intake, liberal potassium intake, and 3 g protein/kg/day Moderate caloric intake, restricted potassium intake, and 1 g protein/kg/day Which functions does the nurse associate with the epidermis? Select all that apply. Serves as an energy reserve Provides cells for wound healing Serves as a mechanical shock absorber Inhibits proliferation of microorganisms Allows the photoconversion of 7-dehydrocholesterol to vitamin D A client’s wound is healing. Which event occurs in the proliferative phase of wound healing? Thinning of scar tissue Strengthening of collagen Formation of "granulation" tissue Increase in capillary permeability Which technology would the nurse use to reduce chronic ulcers by removing fluids from the wound? Electrical stimulation Topical growth factors Hyperbaric oxygen therapyNegative pressure wound therapy A client is admitted to the hospital for the medical management of burns over 18% of the body’s surface. What should the nurse teach the client to help manage pain during dressing changes? Deep breathing exercises Progressive muscle relaxation Active range-of-motion exercises Important elements of wound care The nurse teaches a health class about communicable diseases and states that the virus that causes chickenpox can also cause another disease. Which disease is the nurse describing? Athlete’s foot Herpes zoster German measles Infectious hepatitis After assessing the color of a client’s nail beds, the primary healthcare provider concludes that the client has trauma to the nail beds. Which variations in nail color might the client have? Red color Blue color White color Yellow-brown color Which bacterial skin infections are caused by group A β-hemolytic streptococci? Select all that apply. Furuncle Cellulitis Impetigo Folliculitis Erysipelas A client has a diagnosis of partial-thickness burns. While planning care, the nurse recalls that the client’s burn is different than full-thickness burns. Which information did the nurse recall? Partial-thickness burns require grafting before they can heal. Partial-thickness burns are often painful, reddened, and have blisters. Partial-thickness burns cause destruction of both the epidermis and dermis. Partial-thickness burns often take months of extensive treatment before healing. During a first aid class, a student asks what should be done if a person’s clothes catch on fire. The nurse explains that after the flames are extinguished it is most important to perform this action. Which action did the nurse describe? Give the person sips of water. Assess the person’s breathing.Cover the person with a warm blanket. Calculate the extent of the person’s burns Which skin lesion in found in clients with acne? Wheal Plaque Vesicle Pustule What factors put a client at risk for bacterial infections? Select all that apply. Dry skin Underweight Atopic dermatitis Diabetes mellitus Systemic antibiotics A client’s burn wounds are scheduled to be debrided mechanically. Which equipment will the nurse prepare? Enzymatic agents Scissors and forceps Autolytic semi-occlusive dressing Continuous passive-motion devic A nurse is caring for a client who is receiving radiation therapy. Which information about skin care should the nurse include in the teaching plan? "Cover the area with a sterile gauze bandage." "Put warm compresses on the site once a day." "Limit lying on the back and unaffected side when sleeping." "Avoid applying lotions and powders over the area." registered nurse teaches a client about the self-care measures to be taken to prevent dry skin. Which statement made by the client indicates the nurse needs to follow up? "I will decrease intake of caffeine and alcohol." "I will avoid wearing tight outfits and tight belts." "I will use deodorant soap in place of alkaline soap." "I will wear splints at night to prevent scratching in deep sleep." Which benign tumor forms on the surface of the client’s epithelium? Fibroma Adenoma PapillomaChondroma Which description could be related to zosteriform-type lesions? Wide distribution Diffuse distribution Bilateral distribution Band-like distribution What are the roles of an unlicensed assistive personnel in skin care? Select all that apply. To assist the client in bathing To apply wet dressings to the skin To report changes in the skin appearance To reinforce teaching as done by the registered nurse To determine whether the client is taking a drug that increases photosensitivity An older adult client is diagnosed with postherpetic neuralgia and reports deep pain. Which skin infection does the nurse expect to observe in the client’s electronic medical record? Cellulitis Candidiasis Herpes zoster Herpes simplex After assessing a dark-skinned client, the nurse concludes that the client has cyanosis. Which assessment color variation helped the nurse reach this conclusion? Grey color Purple color Dark red color Purple-to-brownish color Which nursing action is most important to promote the nutritional status of a client during the acute phase of treatment after extensive burns? Provide a diet high in sodium. Limit caloric intake to decrease the work of the body. Reduce protein intake to avoid overtaxing the kidneys. Administer the prescribed intravenous fluid with the added vitamin C. A client newly diagnosed with scleroderma states, "Where did I get this from?" How should the nurse reply? "The exact cause is unknown, but it is thought to be a result of autoimmunity." "The exact cause is unknown, but it is thought to be a result of ocular motility.""The exact cause is unknown, but it is thought to be a result of increased amino acid metabolism." "The exact cause is unknown, but it is thought to be a result of defective sebaceous gland formation." nurse is teaching a client with pruritus about personal care interventions. Which statement made by the client indicates the nurse needs to intervene? "I will trim my fingernails regularly." "I will wear mittens or splints at night." "I will apply moisturizing lotion after bath." "I will not file the edges of fingernails." While caring for an obese client who underwent a cholecystectomy, the nurse notices a separation in the surgical incision. Which complication does the nurse identify? Adhesions Dehiscence Evisceration Contractions Which information may be obtained by palpation? Select all that apply. Turgor Bruises Texture Lesions Moisture content Tissue integrity The primary healthcare provider prescribed imiquimod to a client with a skin infection. What could be the possible condition of the client? Shingles Erysipelas Plantar warts Verucca vulgaris A client reports fever, redness, skin breakdown, and inflammation on the leg. Upon assessment, the nurse finds the area to be tender and edematous with diffused borders. What could be the possible condition? Shingles Cellulitis Folliculitis OnychomycosisThe primary healthcare provider advises the client to apply 0.9% spinosad topical suspension to scalp and hair. Which causative organism would the nurse anticipate for the client’s condition? Tick Lice Mite Bees A client is admitted in the primary healthcare center for treatment of electrical burns. Which technology should the nurse expect will be used for the treatment? Skin substitutes Electrical stimulation Topical growth factors Hyperbaric oxygen therapy While completing an assessment, the nurse finds that a client has decreased thickness and excessive dryness of the epidermis. Which clinical finding is associated with this skin assessment? Skin tears Skin cancer Skin fragility Skin hyperplasia Which information should the nurse include in a teaching plan for a client whose burns are being treated with the exposure (open) method? Aseptic techniques are required. Plants, but not flowers, are allowed. Equipment will be shared with others. Dressings will be changed evey 3 days. A client is being treated for pressure ulcers. The primary healthcare provider advises the client to eat foods with high amounts of vitamin C. What is the role of vitamin C in wound healing? Vitamin C aids in the process of epithelialization. Vitamin C helps in the synthesis of immune factors. Vitamin C increases the metabolic energy required for inflammation. Vitamin C is required for collagen production by fibroblasts. Which type of debridement is most often used to quickly remove large amounts of a client’s nonviable tissue? Surgical debridement Autolytic debridement Enzymatic debridement Mechanical debridementA nurse is assessing the skin of an older adult. Which findings will the nurse determine are expected? Select all that apply. Scaly skin Tenting of skin Transparent skin Increased wrinkles Pigmented lesions While assessing the skin of a client, the primary healthcare provider identifies actinic keratosis. Which clinical findings support this conclusion? Erythematous, barely elevated plaques Elevated, dry, hyperkeratotic scaly papules Variegated colors of tan, brown, black within a single mole Thin, scaly, erythematosus plaque without invasion into the dermis The nurse is caring for a client with a body surface burn injury of 55%. Which information will the nurse consider when planning care for this client? Is prone to poor healing because of a hypermetabolic state Has a decreased risk of infection when in a hypermetabolic state Needs a cool environment to decrease caloric need Will need 20 calories/kg during the healing process Which action should be the nurse’s first priority for a client with major burns? Assessing airway patency Checking the client from head to toe Administering oxygen as needed Elevating the extremities if no fractures are noticed A person on the beach sustains a deep partial-thickness burn because of a severe sunburn. What is the best first-aid measure the nurse can instruct the person to apply before seeking healthcare? Cool, moist towels Dry, sterile dressings Analgesic sunburn spray Vitamin A and D ointment A client with vesiculopustular lesions with honey-colored crusts on the face visits a primary healthcare provider. Which bacterial condition is suspected? Cellulitis Impetigo Carbuncle ErysipelasA client with scleroderma is assessed by a speech therapist after choking and having difficulty with chewing and swallowing. Which dietary information should the nurse reinforce with the client? "Ingest semisoft foods for meals." "Take frequent sips of water with snacks." "Maintain three meals per day but chew carefully." "Use a local anesthetic mouthwash before eating." The nurse teaches a client about cleaning the skin to prevent pressure ulcers. Which statement made by the client indicates the nurse needs to follow up? "I should gently pat the skin." "I should use mild, heavily fatted soap." "I should wash with tepid rather than hot water." "I should apply powders or talc on a perineum wound." A client who has partial-thickness burns on the chest, abdomen, and right side arrives in the emergency department. Which action will the nurse take first? Remove the client’s clothing. Evaluate whether the client has inhaled smoke. Insert a venous access device in an unaffected arm. Determine the extent of the burns, using the rule of nines. The nurse teaches a client about strategies to reduce burn injuries. Which statement made by the client indicates the need for further teaching? "I should never smoke in bed." "I should never use gasoline to start a fire." "I should never leave hot oil unattended while cooking." "I should never attend to burning candles near open curtains." The nurse is caring for a client who returns from surgery with a catheter that is attached to a portable wound drainage system exiting from the surgical site. Which principle underlying the function of a portable drainage system will the nurse consider when planning care for this client? Gravity Osmosis Active transport Negative pressure The nurse is examining the wound of a client and notes greenish-blue pus. What should the nurse interpret from this finding? Colonization with Proteus Colonization with Pseudomonas Colonization with StaphylococcusColonization with aerobic coliform and Bacteroides Which lesion may alter skin turgor? Cysts Patches Macules Lichenifications A client has non-pitting edema over the tibia. What could be the mostpossible cause of the client’s condition? Endocrine imbalance Inflammatory response Fluid and electrolyte imbalance Venous and cardiac insufficiency A dark-skinned client is suspected of having jaundice. Which part of the client should be examined for yellowish coloration to assess the client’s condition? Hard palate Conjunctivae Palms and soles Sclera adjacent to conjunctiva The nurse is providing postoperative care for a client who had choledocholithotomy. The nurse discovers upon assessment that the skin around the client’s T-tube is raw and excoriated. Which action is best for the nurse to take? Reinforce the dressing when it is wet. Use a skin barrier around the tube’s exit site. Cleanse around the site with an antiseptic solution. Change the type of adhesive tape used on the dressing. The nurse observes some elevated superficial lesions filled with purulent fluid on a client’s skin. Which type of lesion does the nurse suspect? Wheal Plaque Pustule Vesicle A hospitalized client develops an infection at a catheter insertion site. The nurse uses the term iatrogenic when describing this infection. What is the rationale for the nurse’s comment? Poor personal hygiene is the cause. Inadequate dietary intake is the cause. The client’s developmental level is the cause. A procedure performed at the hospital is the cause.A client’s extensive burns are being treated with silver nitrate 0.5% dressings. A week after treatment is begun, the nurse identifies that the client’s sodium level is 135 mEq/L (135 mmol/L) and the potassium level is 3.0 mEq/L (3.0 mmol/L). The nurse notifies the primary healthcare provider. Which prescription should the nurse be prepared to administer? Add potassium chloride (KCl) to the existing intravenous (IV) lactated Ringer solution. While assessing a client, the nurse finds changes in the integumentary system due to aging. The nurse suspects decreased sebum gland production. What education would the nurse provide to help the client prevent skin complications? "Use soap with a high fat content." "Do not squeeze your nasal pores." "Lower the water heater temperature." "Avoid frequent bathing with hot water." While assessing a client, the nurse observes a yellow-orange discoloration in the mucous membranes and sclera. Which underlying cause may be associated if red blood cell hemolysis has occurred? Decreased hemoglobin level Increased serum carotene level Increased blood flow to the skin Increased total serum bilirubin level A nurse notices a firm, edematous, irregularly shaped skin lesion on a client who reports an insect bite. Which skin lesion is this? Wheal Plaque Vesicle Pustule A client has thin, dark-red vertical lines about 1 to 3 mm long in the nails. Which diseases are associated with this physiologic alteration in the client? Select all that apply. Psoriasis Trichinosis Cardiac failure Diabetes mellitus Bacterial endocarditis While assessing the hair of a client with a complaint of hair loss, the nurse notices straightening combs on the scalp. Which condition does the nurse suspect in the client? Vitiligo Nevus of OtaPseudofolliculitis Traction alopecia The registered nurse asked the student nurse to care for a client whose dermal-epidermal junction is flattened. On assessing the client, the registered nurse observes that the risk for skin tears is increased. Which action of the student nurse may have resulted in this condition? Taping the client’s skin Encouraging the client to take vitamin D supplements Assisting the client to change positions at 4-hour intervals Avoiding the removal of the client’s adhesive wound dressings A client is scheduled for skin cancer surgery and has not signed the consent form. Which situation will cause the nurse to legally delay signing the operative consent? Ambivalent feelings are present and acknowledged. A sedative type of medication has been given recently. A complete history and physical has not been performed and recorded. A discussion of alternatives with two primary healthcare providers has not occurred. A client receives an autograft for a severe burn and is taught how to change the dressing. One week after receiving the graft, the client identifies that the edges of the graft are curling up and asks the nurse about it. Which is the best response by the nurse? "May I take a look at it?" "It’s time for another graft." "Is there any sign of redness?" "It is supposed to curl up at the edges." A nurse is caring for a client who has a burn in the emergent stage. Which assessment is the highest priority? Extent of burn Cause of burn Where it occurred Type of first aid given A state’s Nurse Practice Act (Canada: Provincial/Territorial Registered Nurse Act) does not allow a registered nurse (RN) to suture wounds. The primary healthcare provider offers to teach the RN how to suture and tells the RN that minor wounds may be sutured without supervision. Which action should the nurse take? Refuse to suture wounds Follow the primary healthcare provider’s instructions Agree to suture wounds in the primary healthcare provider’s presence Report the situation to the state board of nursing (Canada: Provincial/Territorial RN Association)A client is admitted to the hospital after a motor vehicle accident with multiple abrasions and lacerations to the chest and all four extremities. The nurse helps the client select food items for the upcoming meals. Which food items will the nurse recommend? Meatloaf and tea Meatloaf and strawberries Chicken soup and baked apple Chicken soup and buttered bread While assessing the skin of an older client, the nurse finds skin transparency and fragility. Which nursing instructions will benefit the client? "Do not place tape on the skin." "Take multiple vitamins on a daily basis." "Refrain from exposure to skin irritants." "Keep an eye on any pigmented lesions." The registered nurse has instructed the client about effective ways of reducing burn injury. Which statement made by the client shows ineffective learning? "I will refrain from smoking when lying in bed." "I will set the bathing water temperature below 160° F." "I will use a potholder when taking the food from an oven." "I will keep the screens and doors closed on the front of any fireplace." While assessing the skin of a client, the nurse observes weeping papules, fissuring, and lichenification on the client’s foot. What could be the possible diagnosis of the client? Drug eruption Atopic dermatitis Contact dermatitis Non-specific eczematous dermatitis The nurse is caring for a client with a closed soft tissue injury. How will the nurse describe this injury? As an abrasion As a contusion As a laceration As an avulsion A client with a smoking habit visited the primary healthcare provider with a complaint of lesions on the mouth and lips. Which complication does the nurse expect in the client? Basal cell carcinoma Malignant melanoma Squamous cell carcinomaCutaneous T-cell lymphoma A carpenter with full-thickness burns of the entire right arm confides, "I’ll never be able to use my arm again and I’ll be scarred forever." Which initial response by the nurse is best? "The staff is taking steps to minimize scarring." "Think about how lucky you are. You are alive." "Try not to worry for now. Concentrate on your range-of-motion exercises." "I know you’re worried, but it is too early to tell how much scarring will occur." As part of the teaching plan for a client with scleroderma, the nurse addresses the need for special skin care. Which instructions will the nurse provide to the client? Keep the hands warm. Use calamine lotion for pruritus. Apply warm soaks to the infected areas. Take frequent baths to remove scaly lesions. The nurse is advising an older adult client to apply moisturizer when the skin is moist. Which physical change in the client is associated with this advice? Thinning subcutaneous layer Degeneration of elastic fibers Decreased dermal blood flow Benign proliferation of capillaries A client is admitted to the hospital with severe burns. Which client response should the nurse anticipate during the acute phase of burn recovery? Unstable vital signs Decreased urinary output High serum potassium levels Reduced intravascular fluid volume The nurse is caring for a client who underwent intestinal surgery 3 days ago and notices brownish pus with a fecal odor draining from the incision. What should the nurse infer from this finding? Colonization with Proteus Colonization with Pseudomonas Colonization with Staphylococcus Colonization with aerobic coliform and Bacteroides Which drugs used for the treatment of plaque psoriasis will the nurse administer subcutaneously? Select all that apply. Alefacept InfliximabEtanercept Adalimumab Ustekinumab A nurse notices an isolated erythematous pustule with hair growing from the center of the lesion in the buttock of a client. Which diagnosis can the nurse anticipate being observed in the client’s electronic medical record? Cellulitis Folliculitis Candidiasis Dermatophytosis While assessing a client, the nurse observes solar lentigines on the face and back of the hands. What changes in the skin may the nurse suspect to be the reason for the client’s symptoms? Increased permeability Decreased extracellular water Decreased activity of sebaceous glands Increased focal melanocytes in the basal layer with pigment accumulation What instruction would the nurse be most likely to give a client with reduced sensory perception to prevent injury from scalding? "Apply moisturizers." "Use a bath thermometer." "Dress warmly in cold weather." "Avoid frequent bathing with hot water." A client has a basal cell carcinoma that is scheduled to be removed. The client expresses concerns that the cancer has metastasized. Which is the best response by the nurse? "You are a low surgical risk." "I can understand how you must feel." "Basal cell tumors usually do not spread." "The primary healthcare provider probably caught it just in time." A client reports diminished sensations of pain, touch, and temperature on the skin. The nurse touches the skin and finds it cool. Which skin changes should the nurse relate to the client’s findings? Degenerated elastic fibers Decreased blood flow to the skin Increased melanocytes in basal layer Decreased activity of the apocrine glands The nurse is evaluating the condition of a client with burns of the upper body. Which finding will alert the nurse of a potential respiratory obstruction?Deep breathing Hoarse quality to the voice Pink-tinged, frothy sputum Rapid abdominal breathing Which topical immunomodulator is used to treat a client with atopic dermatitis? Mupirocin Tacrolimus Clindamycin Erythromycin The primary healthcare provider instructs the nurse to monitor serum creatinine and blood urea nitrogen in a client who is on therapy for burn wounds. Which medication most likely has been prescribed to the client? Nitrofurantoin Mafenide acetate Silver sulfadiazine Gentamicin sulfate A client with a skin infection on the hand reports itching near the site of infection. Upon assessment, the nurse notices serpiginous patches with elevated borders. What could be the possible diagnosis? Tinea pedis Tinea capitis Tinea manus Tinea corporis A client with third-degree burns asks a nurse, "Why do I need a temporary pigskin graft?" What is the nurse’s best response? "It helps debride necrotic tissue." "It promotes rapid healing of the wound." "When sutured in place, it provides better adherence." "Topical lotions can be used concurrently with the graft." While assessing the skin of a client, the nurse notices edema at the dorsum of the foot and ankle. Which pre-disposing condition does the nurse anticipate in the client? Neurotrauma Hypothyroidism Hyperthyroidism Congestive heart failur The nurse is preparing to insert an intravenous (IV) catheter in a client who is being admitted for uncontrolled diabetes. Upon assessment of the client’s forearm for a potential insertion site, thenurse notes that the client has an excessive amount of hair. What should the nurse do to properly prepare the site for insertion? Clip the hair. Shave the area. Apply a securement device. Prepare the skin with a protectant solution. A client with scleroderma is scheduled to begin a regimen of daily exercises. Which goal will the nurse add to the care plan for these exercises? Preserve muscle strength Support tissue regeneration Maintain a sense of well-being Prevent the spread of the disease A farmer seeks medical care for a large crusty patch of skin on the cheek. The client states that even after using different remedies, it still bleeds easily and has not gotten better. From the client’s history, the nurse suspects skin cancer. Which factor in the client’s history helped the nurse form this conclusion? Exposure to radiation Location of the lesion Self-treatment of lesions Contact with soil contaminants A nurse determines that a client in the acute phase of burns has eaten only a small portion of each meal. What should the nurse assess for in this client? Dehydration Dry brittle hair Prolonged wound healing Clubbing of the fingertips A nurse is caring for a client who sustained a partial-thickness burn to the lower leg accounting for 5% of the total body surface area 1 day ago. Which primary short-term outcome established by the nurse and client will be added to the care plan? The client’s airway will remain patent. The client’s burns will heal free of infection. The client’s urine output will exceed 30 mL every hour. The client’s pain will remain at 2 or less on a scale of 0 to 10. A client with a skin infection in the axilla reports a small, red lesion filled with pus. Upon assessment, the nurse notices the area to be erythematous and tender on palpation with noticeable lymphadenopathy. What could be the possible diagnosis? Shingles CellulitisFuruncle Folliculitis A client has a fracture of the tibia, and a cast is applied. Which action will the nurse take? Cover the cast with plastic wrap until dry. Assist with weight bearing when the client ambulates. Elevate the affected leg above the level of the heart. Insert a finger inside the edges of the cast to check for skin abrasions. A registered nurse assesses clients with dark skin. Which statement made by the registered nurse indicates the need for further teaching? "I should touch the skin to feel its consistency." "I should use a fluorescent light source to assess the skin color." "I should place my hand on the skin to assess the temperature." "I should look for any changes in skin color darker than surrounding skin." The primary healthcare provider sees a client who reports a small pustule at a hair follicle opening with minimal erythema on the scalp. What could be the condition of the client? Furuncle Cellulitis Folliculitis Carbuncle A client was admitted with a burn injury caused by a quick heat flash. The nurse examined the skin and noticed erythema and mild swelling. What type of burn does the nurse suspect? First-degree burn Third-degree burn Fourth-degree burn Second-degree burn A registered nurse teaches a client and the caregiver about pressure ulcer care. Which statement made by the caregiver indicates the need for further teaching? "I should inspect the client’s skin daily." "I should manage the client’s incontinence as quickly as possible." "I should properly dispose of the client’s contaminated dressings." "I should not worry about what the client eats." A client with burns is hospitalized in the emergency department and advised to get an electrocardiogram (ECG) done. Which type of burn injury has the client most likely sustained? Flame burn Chemical burn Electrical burnRadiation burn Which wound care is given to a client with severe burn injuries during the acute phase? Assess extent and depth of burns Provide daily shower and wound care Remove dead and contaminated tissue Assess the wound daily and adjust the dressing While assessing the skin of an older adult, the nurse observes that the skin has a dry and uneven color. Which change is responsible for this condition? Decreased subcutaneous fat Decreased extracellular water Decreased proliferation capacity Decreased activity of sebaceous glands client is admitted with severe burns, is obese, and has pre-existing respiratory problems. Which complication should the nurse anticipate? Necrosis Pneumonia Dysrhythmias Venous thromboembolism Which statement is true related to electrocoagulation therapy that a client is receiving? Electrocoagulation therapy scoops away damaged tissue. Electrocoagulation therapy uses a monopolar electrode. Electrocoagulation therapy has an increased possibility of scarring. Electrocoagulation therapy involves more superficial destruction A client is diagnosed with a dysfunction of the eccrine gland. Which physiologic abnormality might occur in the client? Select all that apply. Drying of hair Drying of surface cells Decreased synthesis of vitamin D Decreased efficiency to cool the body Decreased excretion of waste products through the skin An adolescent girl who has sustained superficial partial-thickness burns of the face because of excessive exposure to the sun exclaims, "Prom night is only 4 weeks away. I’ll never be healed!" What is the nurse’s best response? "The eschar will be healed in 2 weeks." "Liquid makeup base can cover the area." "The edema is expected for several weeks.""Recovery will take about 3 weeks." A nurse is caring for a client admitted for removal of basal cell carcinoma and reconstruction of the nose. Which contributing factor should the nurse question the client about when collecting a health history? Dietary patterns Familial tendencies Amount of tobacco use Ultraviolet radiation exposure A client with scleroderma reports numbness and tingling in the hands followed by blanching of the fingers. The nurse concludes that the client has Raynaud phenomenon. How should the nurse advise the client? "Soak the hands frequently in hot water." "Keep the hands warm by wearing gloves." "Rub the hands briskly to increase circulation." "Take the prescribed anticoagulants to prevent exacerbations." A client who has been in a coma for 2 months is being maintained on bed rest. At which angle will the nurse place the head of the bed to prevent the effects of shearing force? 30 degrees 45 degrees 60 degrees 90 degrees A nurse teaches a client about how to protect a skin area that has undergone radiation treatment. Which statement made by the client indicates the nurse needs to follow up? "I should avoid swimming in saltwater." "I should avoid using adhesive bandages." "I should avoid wearing tight-fitting cloth." "I should avoid rinsing the area with the saline solution." A client with epilepsy reports diffused redness and large blisters on the buccal mucosa. What could be the possible reason for the client’s condition? Administration of pyrazolones Administration of barbiturates Administration of sulfonamides Administration of benzodiazepines A client has a diagnosis of superficial partial-thickness burns. The client asks what layers of skin are involved with this type of burn. Which response by the nurse is most appropriate? The epidermis is damaged. The dermis is damaged partially.The structures beneath the skin are destroyed. Both the epidermis and the dermis are destroyed. A client is admitted to the hospital after sustaining serious burns that involve a large surface of the skin. The nurse is caring for the client during the emergent phase after the injury. Which nursing objective is the priority during this phase? Alleviating pain Preventing infection Replacing blood loss Restoring fluid volume Twelve hours after sustaining full-thickness burns to the chest and thighs a client who is on nothing-by-mouth status (NPO) is reporting severe thirst. The client’s urinary output has been 60 mL/hr for the past 10 hours. No bowel sounds are heard. What should the nurse do? Give the client orange juice by mouth. Increase the client’s intravenous (IV) flow rate. Moisten the client’s lips with a wet 4 × 4 gauze. Offer the client 4 oz (120 mL) of water by mouth. A nurse is caring for a client who sustained skin injuries 3 days ago. Which changes can be noticed by the nurse in the client? Select all that apply . Local edema Erythema Pale color of scar tissue Formation of scar tissue Red colored granulation tissue Sterile warm saline soaks three times a day are prescribed for a client with cellulitis from a puncture wound. The primary nurse places a clean basin, washcloth, and protective pad at the bedside in preparation for the soak but is unable to continue the procedure. What should the nurse assigned to complete the soak do? Continue the procedure as started. Collect new supplies before starting. Discuss the type of soak with the primary healthcare provider. Report the primary nurse to the unit’s nurse manager. A client is noted to have thickened toenails that overhang the toes. The registered nurse suspects a fungal infection and instructs the student nurse to examine the fungal infection to confirm the diagnosis. Which action of the student nurse needs correction? Cutting the client’s fingernails straight across Using the client’s fingernails for assessing capillary refill Using the nail appearance alone for assessing fungal infectionAssessing skin next to the nail to determine whether the thick nail is irritating the skin A client with a reddish-blue generalized skin alteration is hospitalized. Laboratory findings show an increase in the overall amount of hemoglobin. Which condition might the nurse suspect? Albinism Addison’s disease Polycythemia vera Methemoglobinemia The nurse is providing care for a client who is on bed rest. Which action will the nurse take to prevent skin breakdown for this client? Massage the bony prominences. Promote range-of-motion activities. Maintain a sheepskin pad under the client. Encourage the client to move in the bed as much as possible. The nurse is caring for a client with a burn injury and suspects atelectasis and hypoxia. Which age-related changes should the nurse associate these findings? Reduced mobility Reduced healing time Reduced thoracic compliance Reduced inflammatory and immune responses A nurse is preparing to administer preoperative medication to a client scheduled for incision and drainage of a wound abscess. Which action is essential before the nurse administers the medication? Verify the consent. Have the client void. Check the vital signs. Remove the client’s dentures. After surgery, a client has a portable wound drainage system in place. Which action should the nurse take? Irrigate the drainage tube with saline. Apply warm compresses to the involved site. Maintain compression of the drainage system. Keep the involved area in a dependent position. A client had a colostomy surgery and is learning how to care for the skin around the stoma. Which information should the nurse include in the teaching plan for this client? "Cut an opening about inch (0.85 cm) larger than the stomal pattern." ⅓ "Avoid the use of soap and other irritating agents.""Eat yogurt and drink buttermilk and parsley.