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A nurse teaches a client who has very dry skin. Which statement should the nurse include in this clients education?
- A. Use lots of moisturizer several times a day to minimize dryness.
- B. Take a cold shower instead of soaking in the bathtub.
- C. Use antimicrobial soap to avoid infection of cracked skin.
- D. After you bathe, put lotion on before your skin is totally dry.
Correct Answer: D
Rationale: The client should bathe in warm water for at least 20 minutes and then apply lotion immediately because this will keep the moisturizer in the skin. Just using moisturizer will not be as helpful because the moisturizer is not what dehydrates the skin, it is the water. Bathing in warm water will rehydrate skin more effectively than a cold shower, and antimicrobial soaps are actually more drying than other kinds of soap.
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A nurse assesses an older client who is scratching and rubbing white ridges on the skin between the fingers. Which condition should the nurse suspect?
- A. Scabies
- B. Psoriasis
- C. Eczema
- D. Contact dermatitis
Correct Answer: A
Rationale: White ridges on the skin between the fingers, especially with scratching and rubbing, are characteristic of scabies, a parasitic infestation caused by mites. Psoriasis typically presents with scaly, red patches, eczema with inflamed, itchy skin, and contact dermatitis with localized redness from an allergen or irritant. Scabies is the most likely condition based on the description.
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.
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.
A nurse cares for a client who has a deep wound that is being treated with a wet-to-damp dressing. Which intervention should the nurse include in this clients plan of care?
- A. Change the dressing every 6 hours.
- B. Assess the wound bed once a day.
- C. Change the dressing when it is saturated.
- D. Contact the provider when the dressing leaks.
Correct Answer: A
Rationale: Wet-to-damp dressings are changed every 4 to 6 hours to provide maximum debridement. The wound should be assessed each time the dressing is changed. Dry gauze dressings should be changed when the outer layer becomes saturated. Synthetic dressings can be left in place for extended periods of time but need to be changed if the seal breaks and the exudate leaks.
A nurse assesses a client who has a lesion on the skin that is suspicious for skin cancer. Which diagnostic test should the nurse anticipate being ordered for this client?
- A. Punch skin biopsy
- B. Viral cultures
- C. Wood's lamp examination
- D. Diascopy
Correct Answer: A
Rationale: This lesion is suspicious for skin cancer and a biopsy is needed. A viral culture would not be appropriate. A Wood's lamp examination is used to determine if skin lesions have characteristic color changes. Diascopy eliminates polymorph making skin lesions easier to examine.