Nokea
The patient asks the nurse if the placement of the autograft over his full-thickness burn will be the only surgical intervention needed to close his wound. The nurse's best response would be:
- A. "Unfortunately"
- B. an autograft skin is a temporary graft and a second surgery will be needed to close the wound.?"
- C. "An autograft is a biological dressing that will eventually be replaced by your body generating new tissue.?"
- D. "Yes
Correct Answer: C
Rationale: The autograft is the only permanent method of grafting and it uses the patient's own tissue to cover the burn wound. Autografting is permanent and does not require a second surgery unless the graft fails. A biological or biosynthetic graft or dressing is a temporary wound covering. A xenograft is from an animal, usually pig skin and is a temporary graft.
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Assessment findings that would alert the nurse that a client might be at greater risk for deep vein thrombosis include:
- A. Varicose veins and obesity
- B. Client is 35 years old
- C. Client is on an anticoagulant medication
- D. All of the above
Correct Answer: A
Rationale: The development of a blood clot is an increased risk in clients with an impaired circulatory system (e.g., varicose veins), obesity, and age over 40. Anticoagulant medications reduce clot risk.
A patient is undergoing psoralen plus ultraviolet A light (PUVA) therapy for treatment of psoriasis. What action should the nurse take to prevent adverse effects from this procedure?
- A. Cleanse the skin carefully with an antiseptic soap.
- B. Shield any unaffected areas with lead-lined drapes.
- C. Have the patient use protective eyewear while receiving PUVA.
- D. Apply petroleum jelly to the areas surrounding the psoriatic lesions.
Correct Answer: C
Rationale: The eyes should be shielded from UV light (UVL) during and after PUVA therapy to prevent the development of cataracts. The patient should be taught about the effects of UVL on unaffected skin, but lead-lined drapes, use of antiseptic soap, and petroleum jelly are not used to prevent skin damage.
A female client sees a dermatologist for a skin problem. Later, the nurse reviews the client's chart and notes that the chief complaint was intertrigo. This term refers to which condition?
- A. Dry, scaly skin patches
- B. Irritation of opposing skin surfaces caused by friction
- C. Blisters from an allergic reaction
- D. Red, inflamed hair follicles
Correct Answer: B
Rationale: Intertrigo is inflammation caused by friction and moisture between opposing skin surfaces, often in skin folds.
Which intervention should the nurse implement to help toughen the residual limb of a client with a right AKA?
- A. Push residual limb against pillow
- B. Apply elastic bandage around residual limb
- C. Apply vitamin B12 to surgical incision
- D. Elevate residual limb three times a day
Correct Answer: B
Rationale: Elastic bandages shape and toughen the residual limb, preparing it for prosthesis.
Which statement by the daughter of an 80-year-old female client who lives alone warrants immediate intervention by the nurse?
- A. I put a night-light in my mother's bedroom.
- B. I got carbon monoxide detectors for my mother's house.
- C. I changed my mother's furniture around.
- D. I got my mother large-print books.
Correct Answer: C
Rationale: Changing furniture can create fall hazards, especially for elderly individuals.