Nokea
The nurse is providing postoperative care for the client with a split-thickness skin graft on the burn wound at the sole of the right foot. Which is appropriate care for this client?
- A. Immobilization of the graft site
- B. Weight-bearing exercises to the graft site
- C. Assist client out of bed as much as tolerated
- D. Maintain right leg in a dependent position
Correct Answer: A
Rationale: The graft must be immobilized so that it can remain in place and be able to revascularize. The client cannot place weight on the graft site. Bearing weight causes trauma. A dependent position impairs circulation and may cause further tissue injury.
You may also like to solve these questions
The middle-aged client has had two (2) lesions diagnosed as basal cell carcinoma removed. Which discharge instruction should the nurse include?
- A. Teach the client that there is no more risk for cancer.
- B. Refer the client to a prosthesis specialist for prosthesis.
- C. Instruct the client how to apply sunscreen to the area.
- D. Demonstrate care of the surgical site.
Correct Answer: D
Rationale: Surgical site care prevents infection and promotes healing. Ongoing cancer risk remains, prostheses are irrelevant, and sunscreen is secondary post-surgery.
The nurse is assessing the client with atopic dermatitis. Which finding should the nurse expect?
- A. Patchy loss of skin pigmentation called vitiligo.
- B. Trichotillomania, a type of hair loss from compulsive pulling and/or twisting of the hair.
- C. Blistering, redness, and a white patch between the fingers, characteristic of candidiasis.
- D. Atopic dermatitis, which is characterized by redness and irregular, scaly lesions.
Correct Answer: D
Rationale: Atopic dermatitis is characterized by redness and irregular, scaly lesions. Vitiligo shows patchy loss of pigmentation. Trichotillomania involves hair loss from compulsive pulling. Candidiasis shows blistering, redness, and white patches.
When the client asks the nurse about the purpose of the eye shield, which explanation is best?
- A. The shield keeps foreign substances out of the eye.
- B. The shield protects the eye from accidental trauma.
- C. The shield reduces rapid eye movement when dreaming.
- D. The shield promotes dilation of the pupil at night.
Correct Answer: B
Rationale: The shield prevents accidental trauma to the healing eye during sleep.
The client with the condition illustrated is prescribed adapalene topical daily to the affected areas. Which information should the nurse exclude when planning client education?
- A. The client has acne vulgaris, an inflammatory disease involving the sebaceous glands of the skin characterized by papules or pustules or comedones.
- B. Adapalene should be applied once daily in the evening.
- C. Exposing the back to the sun after adapalene (Differin) is applied.
- D. Only a thin film of adapalene should be applied.
Correct Answer: C
Rationale: The nurse should exclude exposing the back to the sun after adapalene (Differin) is applied. This increases the risk for sunburn. Adapalene should also not be applied to sunburned areas. The client has acne vulgaris. Adapalene should be applied once daily in the evening with a thin film.
The nurse is caring for several clients who have burns over different parts of the body. The client who has burns over which part of the body is most at risk of life-threatening complications?
- A. Lower torso
- B. Upper part of the body
- C. Hands and feet
- D. Perineum
Correct Answer: B
Rationale: Burns to the upper body, including the chest and face, increase the risk of respiratory complications, such as airway obstruction or inhalation injury, which are life-threatening.