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On the basis of the nurse's understanding of the etiology of pressure ulcers, the nurse should plan for which intervention to promote the client's skin integrity?
- A. Apply a skin-toughening agent to susceptible areas.
- B. Massage skin areas that remain persistently red.
- C. Keep the head of the bed elevated 30 degrees.
- D. Reposition the client every 2 hours.
Correct Answer: D
Rationale: Repositioning relieves pressure, preventing ulcer progression.
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The school nurse is discussing how to prevent tinea cruris with the football players. Which intervention should the nurse implement?
- A. Instruct the football players to wear tight, snug-fitting jock straps.
- B. Explain the importance of wearing white socks.
- C. Teach the football players to not share brushes or combs.
- D. Discuss the need to dry the groin area thoroughly after bathing.
Correct Answer: D
Rationale: Thorough drying prevents moisture buildup, reducing tinea cruris risk. Tight jock straps trap moisture, socks are irrelevant, and brushes are unrelated.
The nurse is caring for a client who has developed stage IV pressure ulcers on the left trochanter and coccyx. Which collaborative problem has the highest priority?
- A. Impaired cognition.
- B. Altered nutrition.
- C. Self-care deficit.
- D. Altered coping.
Correct Answer: B
Rationale: Altered nutrition is critical in stage IV ulcers to support wound healing. Cognition, self-care, and coping are secondary in advanced wounds.
What is the best advice the nurse can offer the nursing assistant?
- A. Rinse your latex gloves with running tap water before putting them on.
- B. Apply a petroleum ointment to both hands before putting on latex gloves.
- C. Don't wear gloves, but wash your hands vigorously with alcohol after client contact.
- D. Wear two pairs of vinyl gloves when there's a potential for contact with body fluids.
Correct Answer: D
Rationale: Vinyl gloves avoid latex exposure while maintaining protection.
The home health nurse is visiting an elderly client who shows the nurse an area of rough skin with a greasy feel and multiple papules. Which information should the nurse provide the client?
- A. Contact the health-care provider immediately for an appointment.
- B. Tell the client this is a normal aging change and no action should be taken.
- C. Tell the client to discuss this with the HCP at the next appointment.
- D. Have the client buy a wart remover kit at the store.
Correct Answer: C
Rationale: Rough, greasy papules may indicate seborrheic keratosis, requiring HCP evaluation at the next visit. Immediate visits, dismissing as normal, or OTC wart removers are inappropriate.
The nurse is caring for the client with a split-thickness skin graft taken from the thigh to cover a burn on the back. Which intervention should the nurse expect to implement to help reduce the risk of infection at the donor and graft site?
- A. Obtain serial wound cultures of the donor site.
- B. Eliminate plants and flowers in the client's room.
- C. Use clean technique for all wound care procedures.
- D. Administer a continual low dosage of an IV antibiotic.
Correct Answer: B
Rationale: Pseudomonas has been found in plants and flowers, which may be a source of wound infection. Wound cultures are used to confirm an infection but do not prevent one. Sterile technique, not clean technique, would eliminate additional sources of infection. Continual low-dosage antibiotic infusions would not be effective due to increased metabolism in burn clients.