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WorksheetsIntegumentary
Total questions: 25
Worksheet time: 13mins
Which task can a licensed practical nurse (LPN) safely delegate to a nursing assistant?
Applying a topical cream to a client's wound, as prescribed
Performing wet-to-dry dressing changes every 8 hours
Turning a client every 2 hours
Documenting wound healing
Which of the following is appropriate for patient with atopic dermatitis (eczema)
Hot showers help to ease pruritus
Moisturizers should be avoided
antifungals will most likely be ordered
Nails should be cut short and kept clean
A wound culture has been ordered; proper technique includes which of the following
Cleansing the wound first with normal saline
Rolling a sterile swab from the outside around the edges
Use a sterile swab and collect several areas of the wound for sampling
Swab from the inside of the wound outward to collect drainage
Appropriate measure to prevent pressure ulcer formation?
Turning and repositioning every 8 hours
Enforce strict bedrest
Encouraging active and passive range of motion every 8 hours
Restrict fluid intake to 1800mL daily
Which of the following is not an age related change of the integumentary system?
Increase in sweat production
Increase in sebum production
Decrease in pruritus and dryness
Decreased risk of premalignant and malignant skin lesions
Medical treatment focus for a burn client during the emergent phase does not include which of the following
Establishing one or more IV sites
Providing rehabilitation resources to the client
Initiating oxygen therapy
Assess respiratory status
s/s of hypovolemia (fluid volume deficit)
Hypotension and decreased urinary output
Bradycardia and hypertension
Hypotension and bradycardia
Tachycardia and hypertension
Read over the patho of burns p1129 place steps in order
Fluid shifts from bloodstream to extracellular tissue, hypoproteinemia
Generalized edema occurs
Blood is shunted from the kidneys to compensate for a loss of fluid volume
Urine output decreases
Blood is shunted from the kidneys to compensate for a loss of fluid volume
Nursing care for management of wound vac for a patient
Administer analgesics 2 hrs prior to applying the wound vac
The suction container should be monitored once during the shift
Maintain suction intermittently or continuously per physician order
The wound is cleansed with normal saline after applying the wound vac
Which medications are appropriate topical antifungals used to treat fungal infections
Bacitracin and silver sulfadiazine
Benzoyl peroxide and salicylic acid
Topical tretinoin and isotretinoin
nystatin and clotrimazole
Doxycycline and tetracycline
Which of the following is true regarding Herpes Zoster
In some people who have had chickenpox the virus remains latent in nerve tissue until the infection is activated in the form of shingles.
The first symptoms are painless, itching, decreased sensitivity along a nerve pathway.
The infection is not contagious to people who have not had previous exposure to the virus.
Older adults are not as susceptible as middle aged adults.
Which of the following is inaccurate regarding care of the patient with cellulitis
Site should be marked with a marker pen around the borders
Local tenderness, warmth, redness and edema are usually noted on physical assessment
A wound culture may be ordered for open areas around the wound
Fever is not a common sign or symptom
Which of the following are classic symptoms of Impetigo usually seen in the pediatric population?
Inflamed hair follicles with white pustules
Small shiny lesions, clustered
A chancre that will not heal
Vesicle or pustule that ruptures leaving a thick crust
Which should be included in the patient teaching for STIs? pt teaching box p 1097
Women with HPV, HSV should have a pap smear tests every two years because they are at increased risk of cervical cancer
Avoid sexual activity until your infection is cured
HIV is transmitted through blood only therefore you cannot donate blood if HIV positive
The spread of infection is less when lesions are present because the virus can still lie dormant
A nurse is caring for a client who is at risk for skin breakdown. To decrease the risk, the nurse must help ensure that the client remains adequately hydrated. Which action can the nurse take to help determine the client's fluid needs?
Obtain the client's weight daily
Closely monitor intake
Obtain vital signs
Measure intake and output
The nurse is reinforcing prior education for a client on how to prevent development of basal cell epithelioma. Which information is most important for the nurse to tell the client?
Avoid thermal burns
Avoid exposure to sun
Avoid immunosuppression
Avoid exposure to radiation.
The physician orders hourly urine output measurement for a postoperative client. The nurse records the following amounts of output for 2 consecutive hours: 50 ml (8 a.m.)(0800), 60 ml (9 a.m.) (0900). Based on these amounts, what should the nurse do?
Continue to monitor and record hourly urine output
Notify the physician
Irrigate the indwelling urinary catheter
Increase the I.V. fluid infusion rate
Encourage oral fluids
Which of the following nurse actions is appropriate to maintain integrity of the skin when providing care?
Apply moisturizing lotion before a bath is provided for the client.
Reapply dressings before cleansing the area with soap and water first
Apply topical medications after cleansing in skin folds and drying thoroughly
Position legs together to allow any moisture to evaporate
What medical treatment is appropriate for the care of minor burns?
Place the area under warm water and pat thoroughly dry.
Use a pressure dressing gauze wrap to promote circulation
The burn should be cooled under cold running water and then placed on ice
Hold the burned area under cool running water, apply a cool wet compress.
Which signs and symptoms would the nurse expect for a patient in hypovolemic shock
Hypotension, tachypneic, tachycardic, decreased urine output
Hypertension, bradypnea, bradycardic
Hypotension, bradypnea, tachycardic, increased urine output
Hypertension, tachypneic, tachycardic
A client returns from the operating room with a partial-thickness skin graft on the left arm. The donor tissue was taken from the left hip. In planning immediate postoperative care, which interventions should the nurse include?
Change the dressing on the graft site every 8 hours
Elevate the left arm and provide complete rest of the grafted area.
Perform ROM exercises to the left arm every 4 hours.
Encourage the client to ambulate as desired on the first postoperative day.
A client is brought to the emergency department with partial-thickness and full-thickness burns over 15% of the body. Admission vital signs are as follows: blood pressure, 100/50 mm Hg; heart rate, 130 beats/minute; respiratory rate, 26 breaths/minute. Which nursing interventions are appropriate for this client?
Clean the burns with hydrogen peroxide and cover the burns with saline soaked towels
Stop the burning process by cooling the burns by placing the client in an ice bath and wrap loosely gauze around the burn sites
Start an IV, administer IV morphine, Administer tetanus prophylaxis, as ordered
Monitor vitals signs, assess airway for patency and cool the burns with ice
A client weighing 158 lb is ordered to receive 5 mg/kg of cyclosporine daily. How many milligrams should the client receive? Record your answer using a whole number.
(a)
Which nursing interventions are effective in preventing pressure ulcers?
Clean the skin with warm water and a mild cleaning agent; then apply a moisturizer.
When turning the client, slide and avoid lifting him or her.
If the client uses a wheelchair, seat him or her on a rubber or plastic doughnut.
Do not place pillows behind the client or around the client.
The nurse is understands that necrotizing fasciitis is described by which statement?
Affects hair follicles and sebaceous glands, often develop on the face, neck and upper trunk
Viral infection that begins with itching and burning and progresses to vesicles that rupture and form crusts
Caused by the varicella zoster virus resulting in pain and heightened sensitivity along nerve pathways
Infection of deep fascial structures under the skin, organisms excrete enzymes that destroy blood vessels that supply the affected area
