Ignatavicius: Medical-Surgical Nursing,
6th Edition with correct answers 100%
2025 update
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." - Correct AnswerANS: 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." - Correct AnswerANS: 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." - Correct AnswerANS: 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 - Correct
AnswerANS: 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 - Correct AnswerANS: 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 - Correct AnswerANS: 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 - Correct AnswerANS: 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
6th Edition with correct answers 100%
2025 update
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." - Correct AnswerANS: 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." - Correct AnswerANS: 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." - Correct AnswerANS: 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 - Correct
AnswerANS: 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 - Correct AnswerANS: 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 - Correct AnswerANS: 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 - Correct AnswerANS: 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
