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NCLEX Integumentary System/Drugs Questions - NCLEX Questions on Integumentary System/Drugs
Integumentary System/Drugs NCLEX Practice Questions
Question 1.
Ms. Rodriguez is a 35-year-old woman who has sustained bums on her lower leg. She is treated with silver sulfadiazine for the first few' days of her hospitalization. The nursing staff notes that her white blood cell count has decreased significantly and that her skin has turned a bluish-grey color.
Which of the following statements is NOT true about the treatment of Ms. Rodriguez's bums with silver sulfadiazine?
(a) The silver in the drug is toxic to bacteria and has a broad spectaim activity against all gram positive and gram negative bacteria.
(b) The drug can cause leucopenia and bluish-grey discoloration of the skin as side effects.
(c) The drug can cause pain and rash as side effects.
(d) The drug is not irritating to the skin.
Answer:
(c) The drug can cause pain and rash as side effects.
Explanation:
Silver sulfadiazine is a commonly used drug for the treatment of burns. The silver in the drug is toxic to bacteria and has a broad spectrum activity against all gram positive and gram negative bacteria, making it effective at preventing infection. However, the drug can cause leucopenia, or a decrease in white blood cells, as a side effect. It can also cause bluish-grey discoloration of the skin.
Unlike some other bum products, silver sulfadiazine is not irritating to the skin. Mafenide acetate is another burn product that is commonly used, but it can cause pain and rash as side effects and can also cause bone marrow depression and metabolic acidosis. If these symptoms occur with the use of mafenide acetate, the drug should be discontinued for 1 to 2 days and the affected area should be washed.
Rationale:
The correct statement is that silver sulfadiazine can cause leucopenia and bluish-grey discoloration of the skin as side effects. Option (a), stating that the silver in the drug is toxic to bacteria and has a broad spectrum activity against all gram positive and gram negative bacteria, is correct.
Option (b), stating that the drug can cause leucopenia and bluish-grey discoloration of the skin as side effects, is also correct. Option (c), stating that the drug can cause pain and rash as side effects, is incorrect as these are not listed as side effects of silver sulfadiazine. Option (d), stating that the drug is not irritating to the skin, is also correct.
Question 2.
Mrs. Brown is a 55-year-old woman who sustained second- degree bums on her arms and legs in a kitchen fire. Her healthcare provider prescribes silver sulfadiazine to apply to the burns twice daily. After a week of treatment, Mrs. Brown develops a rash and reports pain at the site of the burns.
What should the nurse do in response to Mrs. Brown's symptoms?
(a) Continue to apply silver sulfadiazine as prescribed
(b) Discontinue use of silver sulfadiazine and switch to mafenide acetate
(c) Wash the burns with water and discontinue use of silver sulfadiazine for 1 to 2 days
(d) Administer an antihistamine for the rash and a pain medication for the pain
Answer:
(c) Wash the burns with water and discontinue use of silver sulfadiazine for 1 to 2 days
Explanation:
Silver sulfadiazine is a commonly used medication for the treatment of bums, as it has a broad spectrum of activity against bacteria and is not irritating to the skin. However, like all medications, it can cause side effects, including leucopenia (low white blood cell count) and bluish-gray discoloration of the skin. In this case, Mrs. Brown is experiencing a rash and pain, which are not normal side effects of silver sulfadiazine. The nurse should wash the bums with water and discontinue use of silver sulfadiazine for 1 to 2 days to see if the symptoms resolve.
If the symptoms persist or worsen, the nurse should notify the healthcare provider. Mafenide acetate is another bum product that is bacteriostatic and reduces the growth of bacteria, but it may cause pain, rash, and bone marrow depression or metabolic acidosis. If any of these symptoms occur, the use of mafenide acetate should be discontinued and the affected area washed with water.
Rationale:
The correct action in response to Mrs. Brown's symptoms is to wash the bums with water and discontinue use of silver sulfadiazine for 1 to 2 days. Option (a), continuing to apply silver sulfadiazine as prescribed, is incorrect as Mrs. Brown is experiencing side effects of the medication.
Option (b), switching to mafenide acetate, is also incorrect as mafenide acetate may cause similar side effects such as pain and rash. Option (d), administering an antihistamine and pain medication, may help to alleviate Mrs. Brown's symptoms but does not address the underlying cause of the symptoms, which is the use of silver sulfadiazine.
Question 3.
Mrs. Agrima is a 55-year-old female who was involved in a house fire and sustained bums on her face, arms, and legs. She was taken to the hospital and upon assessment, it was determined that she had superficial thickness burns on her face and superficial partial thickness bums on her arms and legs. The bum area on her face was found to be 9% using the rule of nines, and the bum area on her arms and legs was found to be 18% using the rule of nines.
Which of the following is NOT a type of bum based on depth?
(a) Superficial thickness bum
(b) Deep partial thickness bum
(c) Full thickness bum
(d) Shallow full thickness burn
(e) Deep full thickness burn
Answer:
(d) Shallow full thickness burn
Explanation:
The case study mentions that there are four types of burns based on depth: superficial thickness burns, superficial partial thickness bums, deep partial thickness bums, and full thickness bums. It also mentions that there is a fifth type called deep full thickness bums, which is characterized by damage to internal bones, muscles, and tissues. There is no mention of a bum called shallow full thickness bum in the case study, so (d) Shallow full thickness bum is the correct answer.
Rationale:
The correct answer is (d) Shallow full thickness bum because it is not listed as a type of bum based on depth in the case study. The other options, (a) Superficial thickness bum, (b) Deep partial thickness bum, (c) Full thickness bum, and (e) Deep full thickness bum, are all listed as types of burns based on depth in the case study.
Question 4.
Mrs. Agrima is a 67-year-old female who was involved in a house fire. She sustained burns on her left arm and leg, as well as her face and neck. Upon arriving at the hospital, her vital signs were stable with a blood pressure of 120/80 mmHg, heart rate of 95 beats per minute, respiratory rate of 20 breaths per minute, and oxygen saturation of 97% on room air. The bums on her arm and leg are determined to be deep partial thickness bums, covering a total of 18% of her body surface area based on the rule of nines. The burns on her face and neck are determined to be superficial partial thickness bums, also covering a total of 18% of her body surface area.
Which of the following is NOT a part of the initial management of bum injuries?
(a) Assessing airways, breathing, and circulation
(b) Administering supplemental oxygen if needed
(c) Administering fluids to prevent hypovolemic shock
(d) Applying a skin graft
Answer:
(d) Applying a skin graft
Explanation:
The initial management of bum injuries involves a number of steps to stabilize the patient and prevent complications. These include assessing the patient's airways, breathing, and circulation, administering supplemental oxygen if needed, and administering fluids to prevent hypovolemic shock. Skin grafting is not typically part of the initial management, as it is a more advanced form of wound care that is typically done after the patient has been stabilized and the burn wound has had time to heal.
Rationale:
Option (d), applying a skin graft, is not part of the initial management of bum injuries. During the initial phase, the focus is on stabilizing the patient and preventing complications such as hypovolemic shock, rather than wound care or skin grafting. Options (a), (b), and (c) are all part of the initial management of bum injuries, as they involve assessing and maintaining the patient's airways, breathing, and circulation, as well as administering supplemental oxygen and fluids as needed.
Question 5.
A patient presents to the emergency department with a bum injury on their left arm. The bum is 3 inches in diameter and appears to be a superficial partial thickness bum. The patient reports feeling a tingling sensation at the bum site and has mild edema. The bum occurred when the patient accidentally brushed up against a hot stove while cooking.
What is the size of the burn on the patient's arm according to the "rule of nines?"
(a) 3%
(b) 9%
(c) 18%
(d) 27%
Answer:
(b) 9%
Explanation:
Option (a) (3%) is incorrect because 3% is not a percentage of the body's surface area that is allocated to the amis and hands according to the "rule of nines." Option (c) (18%) is incorrect because 18% is the percentage of the body's surface area allocated to both legs and feet, not just one arm. Option (d) (27%) is incorrect because 27% is not a percentage of the body's surface area that is allocated to any single body part according to the "rule of nines."
Rationale:
The correct answer is (b) (9%) because the "rule of nines" states that each arm and hand make up 9% of the body's surface area. Since the bum is on the patient's left arm, the size of the burn can be determined by multiplying the percentage of the body's surface area that the ami and hand make up by the number of anns affected. In this case, the bum is on one arm, so the size of the bum is 9%.
Question 6.
A 25-year-old male was brought to the emergency department after suffering a burn injury from hot water. Upon examination, it was determined that the burn covered 15% of the patient's body surface area, primarily on the chest and abdomen. The bum was determined to be a deep partial thickness bum.
Which of the following is the most appropriate treatment for the patient's burn injury?
(a) Topical antibiotic ointment
(b) Crystalloid ringer's lactate
(c) Skin grafting
(d) 5% albumin in isotonic saline and ringer's lactate
Answer:
(c) Skin grafting
Explanation:
In this case, the patient has suffered a deep partial thickness burn, which affects the dermis and may require skin grafting to promote healing. A skin graft is a surgical procedure in which healthy skin from another area of the body is transplanted to the burned area to cover the wound. This helps to reduce the risk of infection and promotes healing.
Topical antibiotic ointment may be used as an adjunctive treatment for burns, but it is not the possible treatment for deep partial thickness burns. Crystalloid ringer's lactate and 5% albumin in isotonic saline and ringer's lactate are types of fluids used for fluid resuscitation in burn patients, but they are not the possible treatment for deep partial thickness burns.
Rationale:
The correct answer is (c) Skin grafting, as deep partial thickness bums often require skin grafting to promote healing. A skin graft is a surgical procedure in which healthy skin from another area of the body is transplanted to the burned area to cover the wound. This helps to reduce the risk of infection and promotes healing.
Option (a) Topical antibiotic ointment may be used as an adjunctive treatment for burns, but it is not the possible treatment for deep partial thickness bums.
Option (b) Crystalloid ringer's lactate is a type of fluid used for fluid resuscitation in bum patients. It may be used during the resuscitative phase of bum treatment to replace fluids lost due to the burn injury. However, it is not the possible treatment for deep partial thickness bums.
Option (d) 5% albumin in isotonic saline and ringer's lactate is a type of fluid used for fluid resuscitation in burn patients. It may be used during the resuscitative phase of bum treatment to replace fluids lost due to the bum injury. However, it is not the possible treatment for deep partial thickness burns.
Question 7.
Mrs. X, a 45-year-old woman, was cooking in the kitchen when a pot of boiling water accidentally spilled on her arm. She immediately felt a burning sensation and noticed that her skin had turned red. She was taken to the hospital where she was diagnosed with a superficial thickness burn on her arm.
What is the most appropriate management for Mrs. X's bum injury?
(a) Administer supplemental oxygen
(b) Administer fluids through oral intake
(c) Remove all clothes from the affected area
(d) Administer fluids through intravenous route
Answer:
(d) Administer fluids through intravenous route
Rationale:
Administering fluids through the intravenous route is the most appropriate management for Mrs. X's bum injury as it will help to restore any fluid loss and prevent hypovolemic shock. This is especially important in the emergency or resuscitation phase of bum management.
Option (a), administering supplemental oxygen, may also be appropriate in some cases, but it is not the most important management in this situation. Option (b), administering fluids through oral intake, is not appropriate as the patient's gastrointestinal function is likely to be impaired after the burn injury. Option (c), removing all clothes from the affected area, is not relevant to the management of a superfici al thickness bum.
Question 8.
A 35-year-old male patient has suffered a bum injury on his left ami. The bum is a deep partial thickness bum, with a red surface and white color on the deep areas. The burn covers 15% of the patient's body surface area, with the majority of the bum located on the ami and hand. The patient is experiencing moderate edema and has altered gastrointestinal function.
Which of the following is the most appropriate fluid resuscitation formula for this patient?
(a) Modified Brooke
(b) Parkland
(c) Modified Parkland
(d) Isotonic saline
Answer:
(a) Modified Brooke
Rationale:
Modified Brooke is the most appropriate fluid resuscitation formula for this patient because it is a 5% albumin solution in isotonic saline and ringer's lactate, which can be given intravenously to replace the fluid loss from the burn. It is specifically recommended for deep partial thickness bums, which is the type of bum the patient has.
Parkland and Modified Parkland are also options for fluid resuscitation, but they are crystalloid solutions which may not be as effective as an albumin solution in replacing fluid loss in deep partial thickness bums. Isotonic saline is not a recommended option for burn patients because it does not contain any protein, which is necessary for replacing fluid loss in bums.
Question 9.
A 35-year-old male patient has suffered severe burns on his right arm and leg due to an accident at a construction site. Upon examination, the burns are found to be full thickness with a surface area of 18% on the arm and 36% on the leg. The patient is in a state of hypovolemic shock and is immediately given fluid resuscitation using modified Brooke formula. His vitals are stable and he is placed on a cardiac monitor. The patient's airways, breathing, and circulation are checked and found to be within nomial limits.
Which of the following is NOT a type of burn injury?
(a) Superficial thickness bum
(b) Deep full thickness burn
(c) Deep partial thickness bum
(d) Congenital burn
Answer:
(d) Congenital burn
Explanation:
A congenital burn is a bum injury that occurs during fetal development due to various factors such as maternal infections, drug abuse, or exposure to harmful substances. This type of burn inj ury is not mentioned in the case study and is not one of the types of bum injuries discussed. The other options, namely superficial thickness burn, deep full thickness bum, and deep partial thickness burn, are all types of bum injuries mentioned in the case study.
Option (a) Superficial thickness bum refers to a bum injury that affects only the epidermis and has a tingling sensation. Option (b) Deep full thickness bum refers to a burn injury in which the entire dermis and epidermis are destroyed and the bum affects internal bones, muscles, and tissues. Option (c) Deep partial thickness bum refers to a bum injury in which the skin is red on the surface and white on deep areas and skin grafting may be necessary.
Question 10.
Which of the following is a treatment option for mild acne?
(a) Oral antibiotics
(b) Glucocorticoids
(c) Topical antimicrobials
(d) Isotretinoin
Answer:
(c) Topical antimicrobials
Explanation:
Option (a) Oral antibiotics are recommended for moderate acne, not mild acne. Option (b) Glucocorticoids are a treatment option for milder forms of psoriasis, not acne. Option (d) Isotretinoin is a treatment option for severe acne, not mild acne. Therefore, (c) Topical antimicrobials is the correct option as it is a treatment option for mild acne.
Question 11.
Sanjeeta is a 23-year-old woman who has been suffering from severe acne for several years. She has tried a variety of over- the-counter products and topical medications, but nothing seems to be helping. She decides to visit a dermatologist for further treatment. The dermatologist diagnoses her with severe acne and prescribes isotretinoin as the recommended treatment. Sanjeeta is hesitant to take the medication because she has heard about the potential side effects, including bone marrow depression and ulcerative colitis.
Which of the following is the most effective treatment option for severe acne?
(a) Gentle cleansing
(b) Topical antimicrobials
(c) Oral antibiotics
(d) Isotretinoin
Answer:
(d) Isotretinoin
Explanation:
Isotretinoin is a medication that is specifically designed to treat severe acne. It works by reducing the production of oil in the skin, which can help to prevent the formation of new acne lesions. It is generally considered to be the most effective treatment option for severe acne because it can help to clear up the skin quickly and prevent new breakouts from occurring. Other treatment options, such as gentle cleansing and topical antimicrobials, may not be as effective for severe acne because they do not address the underlying causes of the condition.
Rationale:
Isotretinoin is the recommended treatment option for severe acne. The other options listed (gentle cleansing, topical antimicrobials, and oral antibiotics) are all taken as treatment options for mild or moderate acne. Therefore, option (d) Isotretinoin is the most effective treatment option for severe acne.
Question 12.
The nurse in the burn unit is providing discharge instructions for a patient who received a skin graft due to deep partial thickness burns from a work accident at a chemical plant. Which instruction does the nurse include that is most important for the patient to remember?
(a) Continue physical therapy
(b) Maintain a low-protein, high-fiber diet
(c) Protect the skin graft from direct sunlight
(d) Use cosmetic camouflage techniques
Answer:
(c) Protect the skin graft from direct sunlight
Explanation:
A skin graft is a flap of donor skin either from another part of the body or from another person to cover exposed tissue as the result of injury, infection, or burn. In order to prevent burning and sloughing of the new skin graft, it must be protected from direct sunlight.
Rationale:
(a) is incorrect because physical therapy is important but not most important.
(b) is incorrect because burn patients need a high-protein, high-calorie diet. High-fiber diet is indicated for patients at risk for constipation, not necessarily burn patients.
(d) is incorrect because cosmetic camouflage creams are used to decrease the visibility of scarring from burns, but this is not the nurse’s main concern. This is a psychosocial issue. Preventing the newly growing tissue at the burn site from sunlight is a greater physical concern.
Question 13.
A patient is in the clinic for treatment of herpes zoster (shingles). When assessing the patient, which characteristics would the nurse expect to find?
(a) Clustered skin vesicles
(b) Generalized rash on the body
(c) Small blue-white spots with red base
(d) Fiery red, edematous rash to the cheeks
Answer:
(a) Clustered skin vesicles
Explanation:
Herpes zoster (shingles) is the reactivated form of varicella zoster (chicken pox) from the latent state that is characterized by red skin rash with clustered skin vesicles. The rash is painful and contagious and treated with corticosteroids. Medications such as acyclovir are prescribed for treatment. It is important for the nurse to obtain a baseline CBC and check renal function while on this medication. Remind clients that they are contagious when lesions are open and draining. Active shingles in the hospital requires airborne precautions.
Rationale:
(b) is incorrect because herpes zoster is not characterized by a generalized rash.
(c) is incorrect because herpes zoster is not characterized by small blue-white spots with red base. This describes Koplik’s spots, which occur on the inside of the cheeks and inner surface of lower lip during the incubation of measles.
(d) is incorrect because herpes zoster is not characterized by a fiery red, edematous rash to the cheeks. This is a symptom of Fifth’s Disease.
Question 14.
A patient is admitted to the emergency room for frostbite to the toes. When assessing the patient’s toes, which of the following characteristics would the nurse expect to find?
(a) Pink, edematous toes
(b) Bright red skin and nail beds edematous
(c) Hemorrhagic vesicles, evolving into necrotic ulcers
(d) White skin, insensitive to touch
Answer:
(d) White skin, insensitive to touch
Explanation:
Frostbite is an injury that involves the freezing of the skin and underlying tissues. Skin that is frostbitten first becomes very cold and red, then numb, hard, white or blue in color, and insensitive to touch.
Rationale:
(a) is incorrect because pink skin and edema are not characteristic of frostbite.
(b) is incorrect because bright red skin and edematous nailbeds are not characteristic of frostbite.
(c) is incorrect because these are signs of ecthyma gangrenosum, an infectious complication accompanied by pseudomonas sepsis often seen in immunocompromised patients.
Question 15.
The nurse in the clinic is assessing the skin of a patient and notes the soft-tissue folds surrounding the nails are inflamed. Which question by the nurse would return the most useful information regarding the possible cause of symptoms?
(a) “What is your profession?”
(b) “Do you get professional manicures?”
(c) “Have you been diagnosed with myasthenia gravis?”
(d) “Have you recently had a fungal infection?”
Answer:
(a) “What is your profession?”
Explanation:
Patients who have frequent exposure to water (including homemakers, housekeepers, laundry workers, and bartenders) are commonly diagnosed with chronic paronychia. This condition is characterized by erythema, swelling, and tenderness of the nail folds. If the nurse determines that the patient’s profession is the cause of this condition, the nurse can teach the patient proper skin and nail care to prevent the infection from becoming recurrent or chronic.
Rationale:
(b) is incorrect because asking about professional manicures would not be most useful. Improper manicure technique and decreased equipment disinfection time between clients can lead to micro-trauma and infections.
(c) is incorrect because myasthenia gravis does not cause chronic paronychia. Myasthenia gravis is a progressive neuro-muscular disease which causes muscle weakness that descends down the body.
(d) is incorrect because chronic paronychia is more likely due to bacterial contamination than to fungal infection.
Question 16.
A patient admitted to the medical-surgical unit has ecchymosis noted to both arms by the nurse. What is the first question the nurse should ask?
(a) “Do you use lotion on your skin?”
(b) “Is there a family history of bruising?”
(c) “Are your arms itching?”
(d) “What medications are you currently taking?”
Answer:
(d) “What medications are you currently taking?”
Explanation:
Ecchymosis is a discoloration of skin usually caused by bruising. Some medications that can cause ecchymosis (or easy bruising) including corticosteroids, aspirin, and warfarin. Assessing for current medications is a part of the initial nursing assessment and is important before asking more specific questions.
Rationale:
(a) is incorrect because use of lotion does not contribute to ecchymosis.
(b) is incorrect because ecchymosis is not genetically inherited.
(c) is incorrect because ecchymosis does not typically cause itching.
Question 17.
An overweight female patient is concerned about a rash beneath her breasts. When the nurse teaches the patient about caring for the skin, which patient statement demonstrates good understanding?
(a) “Fluid overload probably caused this rash.”
(b) “I will wash the area with antibacterial soap daily.”
(c) “Powder can be used to keep the skin underneath my breasts dry.”
(d) “I will be scheduling a mammogram soon.”
Answer:
(c) “Powder can be used to keep the skin underneath my breasts dry.”
Explanation:
Excessive moisture usually causes rashes located in skinfolds, including the groin, the axillae, and beneath the breasts, especially in patients who are overweight or obese. The patient should keep the area as dry as possible, and powder can be applied to dry skin to prevent moisture from accumulating throughout the day.
Rationale:
(a) is incorrect because fluid overload is not related to skinfold rash and this statement by the patient does not indicate an understanding of how to properly care for the skin.
(b) is incorrect because antibacterial soap is not necessary for skin hygiene. Antibacterial soap prevents infection, but this rash is not likely infectious in nature.
(d) is incorrect because breast cancer is not related to skinfold rash. Mammograms are indicated for women beginning at the age of 40 or for those who detect a lump or tenderness in the breasts or axillae. Some doctors will order annual mammograms for women younger than 40 who have a family history of breast cancer.
Question 18.
The nurse is assessing the lower extremities of a patient admitted to the medical-surgical unit. When the nurse notes one lower extremity is cool to the touch and pale, what is the next assessment the nurse should perform?
(a) Inquire about family history of disorders of the skin
(b) Palpate bilateral pedal pulses
(c) Check for Homans’ sign
(d) Assess skin turgor
Answer:
(b) Palpate bilateral pedal pulses
Explanation:
Decreased temperature in the skin with pallor localized to one area can indicate vascular flow interference, such as a thrombus. Pedal pulses should be palpated bilaterally to check for distal circulation. The suspected leg’s pulses should be compared to the unaffected leg. If the lower extremity does not have adequate blood flow, the limb is threatened, and the healthcare provider must be notified immediately.
Rationale:
(a) is incorrect because family history of skin disorder is not priority over blood flow.
(c) is incorrect because Homans’ sign screens for deep vein thrombosis (DVT) and is not accurate. Some research now shows that checking for Homans’ sign can actually cause dislodgement of a thrombus from the leg, causing an embolus to move through the circulation, so it is not widely practiced anymore.
(d) is incorrect because skin turgor assesses fluid status. Poor skin turgor can indicate dehydration. This patient is exhibiting signs of impaired circulation, not dehydration.
Question 19.
A patient in the clinic has a history of chronic skin disorder. Which of the following demonstrates effective coping related to the disorder?
(a) Clean nails and hair
(b) Poor eye contact
(c) Disheveled appearance
(d) Scarf draped over the face
Answer:
(a) Clean nails and hair
Explanation:
Psychosocial assessment should be performed to determine effective coping with a chronic skin disorder. The patient is effectively coping if the nails and hair appear clean.
Rationale:
(b) is incorrect because poor eye contact is a sign of anxiety and does not demonstrate effective coping.
(c) is incorrect because disheveled appearance does not demonstrate effective coping. People with chronic skin disorders such as “Picking disorder” often appear unkempt, unclean, and have uneven fingernails with areas of skin that has been picked away from various body locations, mostly the face and hands.
(d) is incorrect because a scarf draped over the face can indicate either religious preference or anxiety and embarrassment, not effective coping.
Question 20.
The nurse on the medical-surgical unit is caring for four patients. Which patient has the greatest risk of developing a pressure ulcer?
(a) 40-year-old with IV antibiotics prescribed for pneumonia
(b) 28-year-old with a fractured femur, on bedrest, in skeletal suspension traction
(c) 70-year-old admitted with incontinence and hemi-paralysis
(d) 72-year-old who ambulates with a walker
Answer:
(c) 70-year-old admitted with incontinence and hemi-paralysis
Explanation:
Pressure ulcers are breakdown of the skin and subcutaneous layers due to decreased circulation, constant moisture, decreased sensation, and constant pressure among many other factors. Immobility related to paralysis and incontinence are significant risk factors for pressure ulcers.
Rationale:
(a) is incorrect because the patient admitted for pneumonia is not at risk for pressure ulcers. Pneumonia patients have decreased lung capacity and may experience fatigue, but the nurse will ambulate as tolerated and this patient is capable of adjusting position in bed to relieve pressure. Antibiotics are not a risk for pressure ulcers.
(b) is incorrect because the patient on bedrest in skeletal suspension traction is at slight risk for pressure ulcers, but this is temporary. Traction prepares patients for surgery with goals to be out of bed and ambulator}- after the procedure.
(d) is incorrect because the patient who ambulates with a walker is not at risk for pressure ulcers.
Question 21.
A patient in the intensive care unit (ICU) has a Stage III pressure ulcer on the left heel. What is the first action the nurse should take?
(a) Draw blood work to assess total protein, albumin, and prealbumin
(b) Obtain a wound culture
(c) Place the patient on bedrest and tell the patient to keep the foot elevated
(d) Assess left lower extremity for temperature, skin color, and pulses
Answer:
(d) Assess left lower extremity for temperature, skin color, and pulses
Explanation:
Pressure ulcers are breakdown of the skin and subcutaneous layers due to decreased circulation, constant moisture, decreased sensation, and constant pressure, among many other factors. The nurse needs to assess the lower extremity for temperature, skin color, and pulses to determine if there is an obstruction to arterial blood flow.
Rationale:
(a) is incorrect because total protein, albumin, and prealbumin are assessed after blood flow. Assessing current circulatory status at the bedside is a greater priority than drawing labs. (These labs will indicate nutritional status and healing ability.)
(b) is incorrect because a wound culture is only performed if there is drainage, odor, or suspicion of infection; culture is not priority or routine when caring for pressure ulcer.
(c) is incorrect because elevating the extremity decreases blood flow to the area and it indicated for swelling, not pressure ulcer.
Question 22.
The nurse is caring for four patients on the medical unit. Which patient needs to be evaluated for wound infection?
(a) Patient who has blood cultures pending
(b) Patient whose wound has a moderate amount of thin, serous drainage
(c) Patient whose white blood cell count was 24,ooo/mm3 this morning
(d) Patient whose wound is decreasing in size
Answer:
(c) Patient whose white blood cell count was 24,ooo/mm3 this morning
Explanation:
Normal white blood cell (WBC) count is 4,500 to io,ooo/mm3. The WBCs are elevated at 24,ooo/mm3, so this patient should be assessed for wound infection.
Rationale:
(a) is incorrect because pending blood cultures are not an indication of wound infection.
(b) is incorrect because thin, serous drainage from a wound is not an indication of wound infection. Signs of infection include elevated WBCs, purulent drainage, yellow- or green- colored drainage, foul odor, and increased pain at the wound site.
(d) is incorrect because a wound decreasing in size is a sign of improvement, not infection.
Question 23.
A patient in the clinic has multiple lesions of the skin. Which of the following lesions should be evaluated by the nurse first?
(a) Beige freckles on the hands and arms
(b) Lower leg mole, irregular shape, blue with white specks
(c) Cluster of pustules to the left axilla
(d) Red, thick pustules with white scales on the upper legs
Answer:
(b) Lower leg mole, irregular shape, blue with white specks
Explanation:
A mole that is irregular and blue with white specks fits criteria for possibly being precancerous or cancerous. The criteria for cancer include variation of color in one lesion, irregular border, size greater than 6mm, change in appearance or new symptom. This patient may need an oncology consult and biopsy.\
Rationale:
(a) is incorrect because freckles are common and benign.
(c) is incorrect because pustules indicate possible infection, but the abnormal mole is the greatest concern because of the risk for cancer.
(d) is incorrect because red, thick pustules with white scales are a symptom of psoriasis and are not priority. Psoriasis, a treatable, autoimmune, chronic skin disorder, is not a medical emergency.
Question 24.
The nurse is preparing to assess a patient with psoriasis. What is the first action the nurse should take?
(a) Don gloves and isolation gown
(b) Shake hands and introduce self
(c) Assess for infection
(d) Ask if the patient could be pregnant
Answer:
(b) Shake hands and introduce self
Explanation:
Psoriasis is red, raised, and scaly patches most commonly on the skin on the elbows, knees, and scalp and caused by autoimmune disease. Patients who have lesions caused by psoriasis often are self-conscious about their skin, so the nurse should shake hands and touch the patient before putting on gloves in order to establish rapport. Therapeutic touch is a component of establishing a healthy nurse-client relationship.
Rationale:
(a) is incorrect because donning gloves and isolation gown is not necessary as psoriasis is not contagious. Psoriasis is an autoimmune, chronic skin disorder that is characterized by periods of exacerbation. When the psoriasis patient is on immunosuppressant medications, they may be more susceptible to infection, but gloves and gown are not necessary.
(c) is incorrect because psoriasis is not infectious. The nurse does not need to assess for infections unless symptoms of infection are present or if the nurse has confirmed the patient is taking immunosuppressant medications.
(d) is incorrect because assessing for pregnancy is done after establishing rapport.
Question 25.
The nurse is teaching the spouse of a patient whose Braden Scale is 9. Which of the following questions does the nurse include when assessing coping needs?
(a) “Do you have trouble using a bedpan for your spouse at home?”
(b) “How do you cope with provision of care at home?”
(c) “How are you preventing pediculosis?”
(d) “Do you share the bed with your spouse?”
Answer:
(b) “How do you cope with provision of care at home?”
Explanation:
The Braden Scale for Predicting Pressure Sore Risk is used to assess sensory perception, activity, mobility, moisture, nutrition, and friction/shear. Score ranges from 6 (highest risk) to 23 (lowest risk) and includes preventive interventions for each range of scores. The patient with Braden Scale of 9 is at a high risk and requires a great deal of assistance for prevention of skin breakdown. This disrupts family routines and adds stress, so the nurse should assess spousal feelings and coping strategies while providing support.
Rationale:
(a) is incorrect because discussion of toileting practices does not assess the spouse’s coping ability. Helping a family member with bedpan toileting can be difficult and requires education about safety and infection control.
(c) is incorrect because preventing pediculosis practices does not assess the spouse’s coping ability. Measures to prevent lice include preventing head-to-head contact and not sharing clothing or towels.
(d) is incorrect because assessing sleeping arrangements does not assess the spouse’s coping ability. Patients with risk for pressure ulcers may need individualized sleeping arrangements at home (wedge pillows, rotating beds) that may make it difficult to share a bed with their spouse.
Question 26.
The nurse on the long-term care unit is caring for a patient with a deep wound to the right lower extremity. A wet-to-damp dressing is utilized to treat the wound. Which of the following interventions does the nurse need to include in the plan of care?
(a) Change dressing every six hours
(b) Assess wound bed daily
(c) Change dressing when saturated
(d) Notify the healthcare provider when decreased fluid drainage is noted from the dressing
Answer:
(a) Change dressing every six hours
Explanation:
Wet-to-damp dressings are utilized for debridement of wounds. Maximum debridement is achieved when the dressing is changed every four to six hours.
Rationale:
(b) is incorrect because assessing the wound bed daily is not frequent enough. The wound should be assessed with every dressing change (four times daily).
(c) is incorrect because the wound dressing should be changed every four to six hours even if the dressing is not saturated. A wound that leaks a lot of fluid may need to be changed more frequently.
(d) is incorrect because decreased fluid drainage is a sign of improvement, and the healthcare provider does not need to be notified.
Question 27.
The oncology nurse is assessing the skin of an older adult in the clinic. Which of the following findings would require an immediate call to the healthcare provider? (Select all that apply.)
(a) Excessive moisture to axilla
(b) Thinning of the hair
(c) Increase of fungal presence in toenails
(d) Multicolored lesion
(e) Spider veins to lower extremities
(f) Dark, 6mm asymmetric lesion to forehead
Answer:
(c) Increase of fungal presence in toenails
(d) Multicolored lesion
(f) Dark, 6mm asymmetric lesion to forehead
Explanation:
The criteria for cancer include variation of color in one lesion, irregular border, size greater than 6mm, and change in appearance or new symptom. The multicolored lesion and the dark, 6mm asymmetric forehead lesion require immediate referral for cancer risk. Fungal infection in the toes is not a normal finding either.
Rationale:
(a) is incorrect because excessive moisture to axilla does not require referral for oncology services.
(b) is incorrect because hair thinning increase does not require referral. Thin hair is common and expected in older adults.
(e) is incorrect because spider veins are common and do not pose significant threat. This finding does not require referral.
Question 28.
The nurse is caring for a patient who has a non-healing wound. Which of the following focused assessments does the nurse perform for development of the plan of nursing care? (Select all that apply.)
(a) Height and weight
(b) Allergies
(c) Alcohol use
(d) Prealbumin lab results
(e) Liver enzyme lab results
Answer:
(a) Height and weight
(b) Allergies
(c) Alcohol use
(d) Prealbumin lab results
Rationale:
Wound healing is largely dependent upon nutritional status, so the nurse needs to assess serum prealbumin levels. Height/weight and alcohol use will also help determine nutritional needs. The patient with a non-healing wound needs a high-protein and high- calorie diet to contribute to healing. A non-healing wound may require the use of additional antibiotics, so assessing for allergies is important as well.
(e) is incorrect because liver enzyme results does not provide wound healing information.
Question 29.
The nurse in the oncology clinic is teaching a patient how to perform self-examination of the skin monthly. Which of the following statements does the nurse include? (Select all that apply.)
(a) “Look for irregular borders and asymmetry.”
(b) “Look for color variations.”
(c) “Examine lesion distribution over body sections.”
(d) “Expect some edema and swelling.”
(e) “Focus on itchy skin areas.”
Answer:
(a) “Look for irregular borders and asymmetry.”
(b) “Look for color variations.”
(c) “Examine lesion distribution over body sections.”
Explanation:
The criteria for cancer include variation of color in one lesion, irregular border, size greater than 6mm, and change in appearance or new symptom. The patient should be taught to look for these characteristics by examining one body section at a time, with every skin assessment.
Rationale:
(d) is incorrect because edema and swelling of tissues is not expected and should be reported to the healthcare provider.
(e) is incorrect because itchy skin areas should not be the focus of skin assessment. The patient should be taught to perform a thorough skin assessment, even on non-itchy areas, because areas of concern may not necessarily be itchy.
Question 30.
The nurse is caring for patients on the long-term care unit who have wounds. Which of the following wounds are paired appropriately with their treatment? (Select all that apply.)
(a) Heel ulcer with necrosis: whirlpool treatment
(b) Eschar-covered ulcer to the sacrum: surgical debridement
(c) Sunburn and erythema: 20-minute warm water soak
(d) Urticaria: wet-to-dry dressing
(e) Sacral ulcer with purulent drainage: transparent film dressing
Answer:
(a) Heel ulcer with necrosis: whirlpool treatment
(b) Eschar-covered ulcer to the sacrum: surgical debridement
Explanation:
Necrotic tissue must be removed in order to assist with tissue healing. Whirlpool treatment is appropriate for removing areas of pressure ulcer necrosis. Eschar usually requires surgical debridement for wound healing.
Rationale:
(c) is incorrect because warm water is not recommended for erythema and sunburn. Cool water and NSAIDs are appropriate interventions for sunburn. Avoidance of further sun exposure is also recommended.
(d) is incorrect because wet-to-dry dressing is not recommended for urticarial (hives.) Urticaria involves intensely pruritic, raised wheals and is treated with antihistamines. The nurse should educate the patient about avoiding triggers.
(e) is incorrect because transparent film dressing is not recommended for pressure ulcers, which are already presenting with drainage. Appropriate dressings are an essential component of pressure ulcer care. Transparent film dressings are to be used preventatively for skin areas that are at risk for friction injury or injury from tape. A pressure ulcer that is draining purulently requires a silver-impregnated dressing.
Question 31.
The nurse is caring for a patient who is immobilized on bedrest after spinal fusion surgery. In order to prevent pressure ulcers, which of the following interventions does the nurse include? (Select all that apply.)
(a) Small pillow placed between bony surfaces
(b) Head of the bed elevated to 45 degrees
(c) Limit proteins and fluids
(d) Lift sheet for repositioning
(e) Reposition in the chair every two hours
(f) Elevate heels off the bed
Answer:
(a) Small pillow placed between bony surfaces
(d) Lift sheet for repositioning
(f) Elevate heels off the bed
Explanation:
Pressure ulcers are breakdown of the skin and subcutaneous skin layers due to decreased circulation, constant moisture, decreased sensation, and constant pressure, among other factors. A small pillow between bony surfaces helps reduce the pressure between those surfaces (such as the knees when the patient is in a side-lying position). The lift sheet (draw sheet) is smaller than the top and bottom sheet of the bed. It is placed flat on top of the bottom sheet, horizontally across the bed underneath the patient.
The lift sheet absorbs moisture from the patient and helps keep the bottom linens dry. It can also be used to help move the patient in bed, preventing shear. The lift sheet may need to be changed more often than the top or bottom sheet. Elevation of heels off the bed surface prevent pressure on the bottoms of the heels, preventing of pressure ulcers.
Rationale:
(b) is incorrect because elevating the head of bed more than 30 degrees will increase pelvic soft tissue pressure and may contribute to pressure ulcers.
(c) is incorrect because tissue integrity is maintained with adequate fluid and protein intake.
(e) is incorrect because this patient is on bedrest and should not be in a chair. Patients in the chair should be repositioned every hour.
Question 32.
The nurse is preparing to admit a patient with disseminated herpes zoster. Which of the following actions should be taken by the nurse? (Select all that apply.)
(a) Choose a room with negative pressure isolation
(b) Assess staff vaccination for or history of chicken pox
(c) Review healthcare provider orders for analgesia
(d) Choose an immune suppressed roommate
(e) Stock gloves in the room
Answer:
(a) Choose a room with negative pressure isolation
(b) Assess staff vaccination for or history of chicken pox
(c) Review healthcare provider orders for analgesia
(e) Stock gloves in the room
Explanation:
Herpes zoster (shingles) is the reactivated form of varicella zoster (chicken pox) from the latent state that is characterized by red skin rash with clustered skin vesicles. The rash is painful and contagious. Disseminated herpes zoster requires standard precautions, airborne, and contact precautions until lesions are dry and crusted. Airborne precautions require a negative pressure isolation room.
Staff members who have not had chicken pox or been vaccinated against it are at increased risk of infection with herpes zoster. The admission orders should be reviewed for analgesia. Healthcare providers will don PPE outside the room of a patient with airborne precautions, and additional gloves should also be stocked in the room.
Rationale:
(d) is incorrect because the patient with herpes zoster should not have a roommate. Patients on airborne precautions are not placed with roommates. Negative pressure isolation rooms are single rooms, generally at the end of the hallway. Immunocompromised patients should not be placed with patients who have infection of any kind.
Question 33.
The nurse is caring for several older patients at a long-term acute care hospital. In order to prevent skin breakdown, which of the following interventions does the nurse implement? (Select all that apply.)
(a) Lift sheet for repositioning in bed
(b) Avoid tape with dressing application
(c) Avoid therapy with the whirlpool
(d) Loose dressings applied to wounds
(e) Pressure-relieving devices
Answer:
(a) Lift sheet for repositioning in bed
(b) Avoid tape with dressing application
(e) Pressure-relieving devices
Explanation:
Pressure ulcers and skin breakdown are breakdown of the skin and subcutaneous layers due to decreased circulation, constant moisture, decreased sensation, and constant pressure, among many other factors. Lift sheets for repositioning reduce shear. An alternative to using tape for dressings is elastic retaining nets (such as Curad) which can be used to keep dressings in place without causing the irritation from tape. Pressure-relieving devices such as a foam mattress-topper, air-fluidized support, and sheepskin overlay all can contribute to reduction of skin breakdown incidences.
Rationale:
(c) is incorrect because there are no contraindications to whirlpool therapy for older patients.
(d) is incorrect because dressings should be applied per healthcare provider orders to provide treatment and not restrict blood flow.
Question 34.
A patient is in the clinic for increased psoriatic lesions. Which of the following questions does the nurse ask in order to identify triggers for worsening of psoriatic lesions? (Select all that apply.)
(a) “Have you been eating chocolate recently?”
(b) “Have you been experiencing increased stress recently?”
(c) “Have you used a public shower recently?”
(d) “Have you travelled internationally recently?”
(e) “Have you experienced other health problems recently?”
(f) “Have you had any medication changes recently?”
Answer:
(b) “Have you been experiencing increased stress recently?”
(e) “Have you experienced other health problems recently?”
(f) “Have you had any medication changes recently?”
Explanation:
Psoriasis is red, raised, and scaly patches on the skin, most commonly on the elbows, knees, and scalp and caused by autoimmune disease. Several factors that can trigger worsening of symptoms in patients with autoimmune diseases include increased stress, other psychological factors, systemic medical problems, certain medications, and other health factors.
Rationale:
(a) is incorrect because chocolate does not trigger worsening of psoriatic lesions.
(c) is incorrect because public showers do not trigger worsening of psoriatic lesions. Public shower floors may contain bacteria, dead skin cells, hair, body fluids, and other microorganisms that contributes to communicable diseases such as tinea pedis (the fungus that causes athlete’s foot), but they do not trigger autoimmune flare-ups.
D is incorrect because international travel does not trigger worsening of psoriatic lesions.
Question 35.
The nurse is working with an unlicensed assistive personnel (UAP) to care for a patient with open skin lesions. When delegating hygiene care to the UAP, which statements does the nurse include? (Select all that apply.)
(a) “Wash your hands before providing care.”
(b) “Wear gloves to bathe the patient.”
(c) “Assess for skin breakdown during bathing.”
(d) “While the skin is still wet, apply lotion to the lesions.”
(e) “Gently scrub the lesions with a damp cloth to help with debridement.”
Answer:
(a) “Wash your hands before providing care.”
(b) “Wear gloves to bathe the patient.”
Explanation:
Standard Precautions should always be followed when caring for patients with open skin lesions. Hand hygiene and wearing gloves are part of Standard Precautions and are appropriate for hygiene care. Gloves are necessary any time a healthcare worker may come into contact with body fluids such as wound exudate from open lesions, urine, blood, stool, sputum, oral mucous, or other mucous membranes.
Rationale:
(c) is incorrect because skin assessment is the responsibility of the nurse. Assessment is not within the scope of practice for a UAP.
(d) is incorrect because lotion should not be applied to open skin lesions. If the UAP is going to apply lotion to a patient, the skin should be thoroughly dried first.
(e) is incorrect because open skin lesions should not be scrubbed. If wound debridement is required, this is the responsibility of the RN.
Question 36.
A patient with eczematous dermatitis calls the nurse to report pain and itching from the eczema. Which of the following non-pharmacologic comfort measures does the nurse instruct the patient to implement at home? (Select all that apply.)
(a) Moist, cool compresses
(b) Topical corticosteroids
(c) Heating pad
(d) Cornstarch in a tepid bath
(e) Back rub using baby oil
Answer:
(a) Moist, cool compresses
(d) Cornstarch in a tepid bath
Explanation:
Eczematous dermatitis, or atopic dermatitis, is a red rash that evolves rapidly and is blistered and swollen, progressing to hardened, dry flaking skin on the face, upper chest, antecubital fossa, and popliteal fossa. The comfort measure goal is decreasing inflammation and debridement of crusts and scales. Moist, cool compresses and cornstarch in a tepid bath can all relieve pain associated with eczematous dermatitis.
Rationale:
(b) is incorrect because topical corticosteroids are not a non-pharmacologic comfort measure. (Topical steroids and antihistamines are often used to treat eczema.)
(c) is incorrect because a heating pad will exacerbate inflammation and pain. Patients with eczema should be taught to avoid prolonged hot baths or showers, clothing that is irritating (rough/wool), or clothing that is too tight and promotes sweating.
(e) is incorrect because baby oil is not appropriate for eczematous dermatitis. Evening primrose oil is an herbal option that is safe for treating eczema.
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