Nokea
Which will the nurse dressing a necrotic pressure injury with a minimal exudate most likely use?
- A. Hydrocolloid dressing
- B. Alginate dressing
- C. Hydrofiber dressing
- D. Transparent film
Correct Answer: A
Rationale: Hydrocolloid dressings are useful in necrotic wounds with little exudate. Alginate and hydrofiber dressings are used for wounds with copious exudate. Transparent film is not absorbent.
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The three major glands of the skin are sudoriferous, ceruminous, and
- A. sebaceous
Correct Answer: sebaceous
Rationale: Sudoriferous glands-sweat glands open into pores on the skin surface and excrete sweat. Ceruminous glands-secrete a waxlike substance called cerumen and are located in the external ear canal. Sebaceous glands-secrete their substance, sebum (an oily secretion), through the hair follicles distributed on the body.
The nurse has staged a pressure injury that has a shallow crater with a dry pink wound bed in which way?
- A. stage 1.
- B. stage 2.
- C. stage 3.
- D. stage 4.
Correct Answer: B
Rationale: Stage 2 pressure injuries appear as a shallow open injury, usually shiny or dry, with a red-pink wound bed without slough. Stage 1 involves intact skin with non-blanchable redness. A stage 3 pressure injury involves full-thickness tissue loss and sometimes subcutaneous fat is visible. At stage 4, there is a full thickness tissue loss with exposed bone, tendon, cartilage or muscle.
Which is the greatest concern during the emergent phase of a burn injury?
- A. joint contractures
- B. Fluid overload
- C. hypovolemic shock.
- D. adrenal failure.
Correct Answer: C
Rationale: Hypovolemic shock is frequently lethal in the emergent period of a severe burn because of the transfer of fluids into the interstitial tissue from the circulating volume. Joint contractures and fluid overload occur during later phases of the burn injury. Adrenal failure is not associated with the emergent period of a severe burn.
Which patient instruction will the nurse reinforce relative to the management of systemic lupus erythematosus (SLE)?
- A. Maintain a balance between rest and activity.
- B. Increase activity to promote mobility.
- C. Increase exposure to the sun to increase vitamin D absorption.
- D. Increase sodium consumption.
Correct Answer: A
Rationale: Balanced rest, activity, and diet will support medication management. It is not necessary to increase activity to promote mobility. Limited sunlight exposure is recommended to prevent photosensitivity. SLE often has kidney involvement, which would require reduction of sodium.
The nurse will provide which instruction regarding reducing the risk factors for melanoma?
- A. Avoid exposure to the sun and use protective measures when exposure occurs.
- B. Have all nevi removed.
- C. Watch for changes in moles, especially on the back.
- D. Use a sun lamp for tanning.
Correct Answer: A
Rationale: Encourage the patient to protect skin from the sun by wearing protective clothing, including a hat with 4-in brim, applying sunscreen all over the body, and avoiding the midday sun from 10 a.m. to 4 p.m. Having all nevi removed is impractical. Watching for changes in moles does not reduce risk factors; it allows for early detection. Sun lamps are just as damaging as the sun.