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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 nurse is teaching the client diagnosed with atopic dermatitis. Which information should the nurse include in the teaching?
- A. Discuss skin care using hydrating lotions and minimal soap.
- B. Tell the client the methods of treating secondary infection.
- C. Explain there are no adverse effects to using topical corticosteroids daily.
- D. Warn the client inhaled allergens have been linked to exacerbations.
Correct Answer: A
Rationale: Hydrating lotions and minimal soap reduce atopic dermatitis flares. Secondary infections, corticosteroid risks, and allergens are secondary teaching points.
Which individual would most likely experience the skin disorder pseudofolliculitis barbae (shaving bumps)?
- A. A male African American soldier.
- B. A female Caucasian hairdresser.
- C. A male Asian food server.
- D. A female Hispanic schoolteacher.
Correct Answer: A
Rationale: Pseudofolliculitis barbae is common in African American males due to curly hair causing ingrown hairs post-shaving. Other groups are less affected.
Which response by the nurse is best at this time?
- A. I'm sure you will look absolutely gorgeous.
- B. I didn't think you were unattractive before.
- C. Your face is swollen with bruises around the eyes.
- D. Your personality is more important than your looks.
Correct Answer: C
Rationale: An honest response about expected swelling prepares the client for recovery.
There is an outbreak of scabies in a long-term care facility. Which instruction should the infection control nurse provide to all client care staff concerning the transmission of this parasitic infection?
- A. Use only hand-washing foam when caring for clients with scabies.
- B. Wear gloves when providing hands-on care for a client with scabies.
- C. Wash all linen and clothes in cold water and dry them outside in the sun.
- D. Instruct clients to use plastic eating utensils for meals.
Correct Answer: B
Rationale: Gloves prevent scabies transmission during direct contact. Hand-washing foam is insufficient, hot water washing is needed, and plastic utensils are irrelevant.
The client with full-thickness burns to 40% of the body, including both legs, is being transferred from a community hospital to a burn center. Which measure should be instituted before the transfer?
- A. A 22-gauge intravenous line with normal saline infusing.
- B. Wounds covered with moist sterile dressings.
- C. No intravenous pain medication.
- D. Ensure adequate peripheral circulation to both feet.
Correct Answer: D
Rationale: Ensuring peripheral circulation prevents ischemic complications during transfer. A 22-gauge IV is too small for major burns, moist dressings are inappropriate for full-thickness burns, and IV pain medication is needed.