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A nurse delegates care for a client who has open skin lesions. Which statements should the nurse include when delegating this clients hygiene care to an unlicensed assistive personnel (UAP)? (Select all that apply.)
- A. Wash your hands before touching the client.
- B. Wear gloves when bathing the client.
- C. Assess skin for breakdown during the bath.
- D. Apply lotion to lesions while the skin is wet.
- E. Use a damp cloth to scrub the lesions.
Correct Answer: A,B
Rationale: All health care providers should follow Standard Precautions when caring for clients with open skin lesions, including hand hygiene and wearing gloves. UAPs are not qualified to assess skin or apply lotion to lesions, and scrubbing lesions is inappropriate as it may cause further damage.
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A nurse assesses a client who presents with an increase in psoriatic lesions. Which questions should the nurse ask to identify a possible trigger for worsening of this clients psoriatic lesions? (Select all that apply.)
- A. Have you eaten a large amount of chocolate lately?
- B. Have you been under a lot of stress lately?
- C. Have you recently used a public shower?
- D. Have you been out of the country recently?
- E. Have you recently had any other health problems?
- F. Have you changed any medications recently?
Correct Answer: B,E,F
Rationale: Systemic factors, hormonal changes, psychological stress, medications, and general health factors can aggravate psoriasis. Psoriatic lesions are not triggered by chocolate, public showers, or international travel.
After teaching a client how to care for a furuncle in the axilla, a nurse assesses the clients understanding. Which statement indicates the client correctly understands the teaching?
- A. I'll apply cortisone cream to reduce the inflammation.
- B. I'll apply a clean dressing after squeezing out the pus.
- C. I'll keep my arm down at my side to prevent spread.
- D. I'll cleanse the area prior to applying antibiotic cream.
Correct Answer: D
Rationale: Cleansing and topical antibiotics can eliminate the infection. Warm compresses enhance comfort and open the lesion, allowing better penetration of the topical antibiotic. Cortisone cream reduces the inflammatory response but increases the infection process. Squeezing the lesion may introduce infection to deeper tissues and cause folliculitis. Keeping the arm down increases moisture in the area and promotes bacterial growth.
A nurse is caring for a client who has a pressure ulcer on the right ankle. Which action should the nurse take first?
- A. Draw blood for albumin, prealbumin, and total protein.
- B. Prepare for and assist with obtaining a wound culture.
- C. Place the client in bed and instruct the client to elevate the foot.
- D. Assess the right leg for pulses, skin color, and temperature.
Correct Answer: D
Rationale: A client with an ulcer on the foot should be assessed for interruption in arterial flow to the area. This begins with the assessment of pulses and color and temperature of the skin. The nurse can also assess for pulses noninvasively with a Doppler flowmeter if unable to palpate with fingers. Tests to determine nutritional status and risk assessment would be completed after the initial assessment is done. Wound cultures are done after it has been determined that drainage, odor, and other risks for infection are present. Elevation of the foot is appropriate after assessment of arterial flow to the area.
After teaching a client who has psoriasis, a nurse assesses the client's understanding. Which statement indicates the client needs further education?
- A. I'll avoid scratching the patches to prevent worsening.
- B. I'll use moisturizers to keep my skin hydrated.
- C. I'll apply sunscreen to protect my skin from UV damage.
- D. I'll take hot baths daily to soothe the lesions.
Correct Answer: D
Rationale: Hot baths can exacerbate psoriasis by drying out the skin and increasing irritation. The other statements reflect appropriate self-care measures for managing psoriasis, such as avoiding scratching, using moisturizers, and protecting skin from UV damage.
A nurse cares for clients who have various skin infections. Which infection is paired with the correct pharmacologic treatment?
- A. Viral infection: Clindamycin (Cleocin)
- B. Bacterial infection: Acyclovir (Zovirax)
- C. Yeast infection: Linezolid (Zyvox)
- D. Fungal infection: Ketoconazole (Nizoral)
Correct Answer: D
Rationale: Ketoconazole is an antifungal medication appropriate for fungal infections. Clindamycin and Linezolid are antibiotics used for bacterial infections, and Acyclovir is an antiviral drug used for viral infections.