NCLEX: Adult Integumentary Questions | Questions and Answers with complete solution

The Nurse is conducting a session about principles of first aid and is discussing the interventions for a snakebite to an extremity. The nurse should inform those attending the session that the FIRST PRIORITY intervention in the event of this occurrence is which action? 1.) Immobilize affected extremity. 2.) Remove jewelry and constricting clothes from the victim. 3.) Place the extremity in a position so that it is below the level of the heart. 4.) Move the victim to a safe area away from the snake and encourage the victim to rest. - Answer: 4 Rationale: While all the answer choices are something you have to do, removing the client away from the threat is the first step because the snake could come back for another bite. After they are safe and resting, then you would do 1,2, and 3 A client calls the emergency department and tells the nurse that he came directly into contact with poison ivy shrubs. The client tells the nurse that he cannot see anything on the skin and asks the nurse what to do. The nurse should make which response? 1.) Come to the emergency department. 2.) Apply calamine lotion immediately to the exposed skin areas. 3.) Take a shower immediately, lathering and rinsing several times. 4.) It is not necessary to do anything if you cannot see anything on your skin. - Answer: 3Rationale: The poison ivy should be washed off immediately in order to reduce the risk of developing a rash. Since the client is currently not having a severe reaction to the poison ivy, they do not need to be seen in the emergency room at this time. Option 4 does not address the problem, so is incorrect. Option 2 (calamine lotion) could be helpful if dermatitis develops, but not useful at this time w hile the poison ivy is still on the skin. A client is admitted to the hospital for treatment of acute cellulitis of the lower left leg. During the admission assessment, the nurse expects to note which finding? 1.) An inflammation of the epidermis only. 2.) A skin infection of the dermis and underlying hypodermis. 3.) An acute superficial infection of the dermis and lymphatics 4.) An epidermal and lymphatic infection caused by Staphylococcus. - Answer: 2