MEDICAL SURGICAL NURSING PRACTICE IGNATAVICIUS 8TH
EDITION TEST BANK
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.
Which client is at greatest risk for pressure ulcer development?
a. Client who has pneumonia
b. Client who requires assistance with ambulation
c. Older client with hypertension
d. Incontinent client with limited mobility - (answer)ANS: D
The client who is confined to a chair has the most risk factors. Being immobile and incontinent
are two significant risk factors for the development of decubiti.
EDITION TEST BANK
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.
Which client is at greatest risk for pressure ulcer development?
a. Client who has pneumonia
b. Client who requires assistance with ambulation
c. Older client with hypertension
d. Incontinent client with limited mobility - (answer)ANS: D
The client who is confined to a chair has the most risk factors. Being immobile and incontinent
are two significant risk factors for the development of decubiti.
