Nokea
When examining the client's skin, which finding would the nurse expect to observe?
- A. Weeping skin lesions on the trunk of the body.
- B. Red skin patches covered with silvery scales.
- C. A red rash containing raised pustules.
Correct Answer: B
Rationale: Psoriasis presents with red patches and silvery scales.
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After touching a hot oven grate, the client telephones the ED asking for advice for the singed fingers. Which initial statement by the nurse is most appropriate?
- A. Wrap ice in a washcloth and put it on the burn area.
- B. Come to the ED so a doctor can assess your fingers.
- C. Run cool water over the burned area on your fingers.
- D. Apply an antibiotic skin ointment to prevent infection.
Correct Answer: C
Rationale: Ice causes vasoconstriction and can worsen the tissue damage. The nurse should collect additional information before advising that the client be seen in the ED. A first-degree burn ordinarily does not require medical care. Cool water will minimize skin redness, pain, and swelling and limit tissue damage. Applying a skin ointment as an initial intervention can trap heat in the tissues; if it has an oily base, it can prevent healing.
The wound care nurse documented a client’s pressure ulcers on admission as 3.3 cm × 4 cm stage II on the coccyx. Which information would alert the nurse that the client’s pressure ulcer is getting worse?
- A. The skin is not broken and is 2.5 cm × 3.5 cm with erythema that does not blanch.
- B. There is a 3.2-cm × 4.1-cm blister that is red and drains occasionally.
- C. The skin covering the coccyx is intact but the client complains of pain in the area.
- D. The coccyx wound extends to the subcutaneous layer and there is drainage.
Correct Answer: D
Rationale: Extension to the subcutaneous layer with drainage indicates progression to stage III or IV, worsening the ulcer. Smaller size, blisters, or pain are less severe.
The nurse is planning care for a newly burned client. What is the priority nursing observation to be made during the first 48 hours after the burn?
- A. Hourly blood pressure
- B. Assessment of skin color and capillary refill
- C. Hourly urine measurement
- D. Frequent assessment for pain
Correct Answer: C
Rationale: Hourly urine measurement is critical in the first 48 hours to monitor fluid resuscitation effectiveness and prevent hypovolemic shock.
The nurse observes the unlicensed assistive personnel (UAP) squeezing the 'blackheads' on an elderly client. Which action should the nurse implement first?
- A. Notify the unit manager of witnessing this activity.
- B. Instruct the assistant to stop this behavior.
- C. Demonstrate the correct way to care for the skin.
- D. Complete an incident report regarding the action.
Correct Answer: B
Rationale: Stopping the UAP prevents harm from inappropriate skin manipulation. Notification, demonstration, and reporting follow.
The client had an allergic reaction to poison oak two (2) weeks ago. He has returned to the clinic with severe itching and weeping vesicles on the arms and legs. Which intervention should the nurse implement?
- A. Obtain a sample of the drainage for culture and sensitivities.
- B. Determine any allergic reactions to any medications taken recently.
- C. Inquire how the poison ivy/oak plants were destroyed.
- D. Assess for any temperature elevation since the last visit to the clinic.
Correct Answer: D
Rationale: Fever suggests secondary infection in persistent poison oak dermatitis, requiring assessment. Cultures, medication allergies, and plant destruction are secondary.