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When transferring a client into a chair, a nurse notices that the pressure-relieving mattress overlay has deep imprints of the clients buttocks, heels, and scapulae. Which action should the nurse take next?
- A. Turn the mattress overlay to the opposite side.
- B. Do nothing because this is an expected occurrence.
- C. Apply a different pressure-relieving device.
- D. Reinforce the overlay with extra cushions.
Correct Answer: C
Rationale: Bottoming out, as evidenced by deep imprints in the mattress overlay, indicates that this device is not appropriate for this client, and a different device or strategy should be implemented to prevent pressure ulcer formation.
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A nurse assesses an older client who is scratching and rubbing white ridges on the skin between the fingers. Which condition should the nurse suspect?
- A. Scabies
- B. Psoriasis
- C. Eczema
- D. Contact dermatitis
Correct Answer: A
Rationale: White ridges on the skin between the fingers, especially with scratching and rubbing, are characteristic of scabies, a parasitic infestation caused by mites. Psoriasis typically presents with scaly, red patches, eczema with inflamed, itchy skin, and contact dermatitis with localized redness from an allergen or irritant. Scabies is the most likely condition based on the description.
A nurse delegates care for a client who has open skin lesions. Which statements should the nurse include when delegating this clients hygiene care to an unlicensed assistive personnel (UAP)? (Select all that apply.)
- A. Wash your hands before touching the client.
- B. Wear gloves when bathing the client.
- C. Assess skin for breakdown during the bath.
- D. Apply lotion to lesions while the skin is wet.
- E. Use a damp cloth to scrub the lesions.
Correct Answer: A,B
Rationale: All health care providers should follow Standard Precautions when caring for clients with open skin lesions, including hand hygiene and wearing gloves. UAPs are not qualified to assess skin or apply lotion to lesions, and scrubbing lesions is inappropriate as it may cause further damage.
A nurse is caring for a client who has a pressure ulcer on the right ankle. Which action should the nurse take first?
- A. Draw blood for albumin, prealbumin, and total protein.
- B. Prepare for and assist with obtaining a wound culture.
- C. Place the client in bed and instruct the client to elevate the foot.
- D. Assess the right leg for pulses, skin color, and temperature.
Correct Answer: D
Rationale: A client with an ulcer on the foot should be assessed for interruption in arterial flow to the area. This begins with the assessment of pulses and color and temperature of the skin. The nurse can also assess for pulses noninvasively with a Doppler flowmeter if unable to palpate with fingers. Tests to determine nutritional status and risk assessment would be completed after the initial assessment is done. Wound cultures are done after it has been determined that drainage, odor, and other risks for infection are present. Elevation of the foot is appropriate after assessment of arterial flow to the area.
A nurse is planning care for a client with a sacral pressure ulcer. Which interventions should the nurse include in the plan of care? (Select all that apply.)
- A. Place a small pillow between bony surfaces.
- B. Elevate the head of the bed to 45 degrees.
- C. Limit fluids and proteins in the diet.
- D. Use a lift sheet to assist with re-positioning.
- E. Re-position the client who is in a chair every 2 hours.
- F. Keep the clients heels off the bed surfaces.
- G. Use a rubber ring to decrease sacral pressure when up in the chair.
Correct Answer: A,D,F
Rationale: A small pillow decreases the risk for pressure between bony prominences, a lift sheet decreases friction and shear, and keeping heels off the bed reduces pressure on high-risk areas. Limiting fluids and proteins is not appropriate as they are essential for tissue integrity. Clients should be repositioned every hour while in a chair, not every 2 hours. A rubber ring impairs capillary blood flow, increasing pressure sore risk.
A nurse cares for clients who have various skin infections. Which infection is paired with the correct pharmacologic treatment?
- A. Viral infection: Clindamycin (Cleocin)
- B. Bacterial infection: Acyclovir (Zovirax)
- C. Yeast infection: Linezolid (Zyvox)
- D. Fungal infection: Ketoconazole (Nizoral)
Correct Answer: D
Rationale: Ketoconazole is an antifungal medication appropriate for fungal infections. Clindamycin and Linezolid are antibiotics used for bacterial infections, and Acyclovir is an antiviral drug used for viral infections.