Nokea
Which of the following would be most important to include in the preadministration assessment of a client who is receiving topical therapy for a skin disorder? Select all that apply.
- A. Size of the area affected
- B. Appearance of the lesions
- C. Report of pain or burning
- D. Client's weight
- E. Blood pressure
Correct Answer: A,B,C
Rationale: The preadministration assessment involves a visual inspection and palpation of the involved area(s). The areas of involvement, including the size, color, and appearance, are carefully measured and documented. The appearance of the skin lesions and reports of pain or burning are noted to establish an accurate baseline for treatment.
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A nurse administering collagenase (Santyl) topically to a client must be certain not to use which of the following products that can inactivate the enzymes in collagenase (Santyl)? Select all that apply.
- A. Detergents
- B. Water
- C. Iodine
- D. Silver
- E. Mercury
Correct Answer: A,D,E
Rationale: A nurse administering collagenase (Santyl) topically to a client must be certain not to use detergents or products containing heavy metals, like mercury and silver, which can inactivate the enzymes in collagenase (Santyl).
A client is prescribed topical betamethasone. Which of the following would the nurse include when explaining the possible adverse reactions that may occur? Select all that apply.
- A. Burning
- B. Dryness
- C. Pruritus
- D. Nausea
- E. Fever
Correct Answer: A,B,C
Rationale: Localized reactions caused by the topical administration of betamethasone that the nurse should discuss with the client include burning, pruritus, irritation, redness, dryness, allergic contact dermatitis, and secondary infection.
A client is prescribed topical triamcinolone. The nurse is aware that the client may experience systemic adverse reactions. Which of the following might the nurse assess? Select all that apply.
- A. Hyperglycemia
- B. Myasthenia gravis
- C. Cushing's syndrome
- D. Nausea
- E. Fever
Correct Answer: A,C
Rationale: Systemic reactions caused by the topical administration of triamcinolone (Aristocort) that the nurse should be alert for include hypothalamic-pituitary-adrenal axis suppression, Cushing's syndrome, hyperglycemia, and glycosuria.
Chlorhexidine gluconate is being used in a client for preoperative skin preparation. Which of the following if noted would alert the nurse to a possible adverse reaction?
- A. Taste perversion
- B. Headache
- C. Deafness
- D. Mild erythema
Correct Answer: C
Rationale: The nurse should monitor for deafness as an adverse reaction to the use of chlorhexidine gluconate. Taste perversion, headache, and mild erythema are adverse reactions to penciclovir.
A nurse is preparing to administer a keratolytic based on the understanding that this drug is used to treat which of the following skin disorders? Select all that apply.
- A. Psoriasis
- B. Warts
- C. Acne vulgaris
- D. Seborrheic keratoses
- E. Corns
Correct Answer: B,D,E
Rationale: Keratolytics are used to treat the following skin disorders: warts, calluses, corns, and seborrheic keratoses.