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1 Post for November 5 on Sat Nov 05, 2011 6:49 pm

kblanken


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15 NCLEX questions related to skin integrity

1. The nurse is caring for a client with an infected Stage 4 pressure ulcer with a significant amount of eschar formation. In planning for care the nurse considers that which nursing intervention(s) would apply for this client? Select all that apply.
A. Wet-moist saline guaze
B. Reposition every two hours
C. Enzymatic debridement
D. Hydrogel dressings
E. Dry gauze dressings
Answer A,B,C,D

2. The nurse explains to the family that a family member needs to have a escharotomy. The nurse includes which of the following statements in the explanation.
A. It is done to prevent ischemia and necrosis
B. It is exactly the same as a fasciotomy
C. It is done to promote drainage of edema fluid
D. It is only done on extremities
Answer A

3. The nurse conduction health promotion about maintaining healthy skin in the communtiy teaches clients that the epidermis has which of the following functions?
A. To protect foreign objects from penetrating mucous membranes
B. To regulate body heat by excretion of perspiration
C. To produce androgens and regulate temperature
D. To protect the tissues from physical damage and prevent water loss
Answer D.

4. A NA will be changing the soiled bed linens of a client with a draining pressure ulcer. Which protective equipment should the NA wear?
A. Mask
B. clean gloves
C. Sterile gloves
D. Shoe protectors
Answer B

5. Which intervention is most appropriate for preventing pressure ulcers in a bedridden elderly client?
A. Slide instead of lifting the client
B. Turn and reposition client every 8 hours
C. Apply lotion after bathing and vigorously rub the skin
D. Post a turning schedule at the client's bedside, and adapt position changes to the client's situation
Answer D

6. A client has a stage two sacral pressure ulcer that's receiving a transparent film dressing. Which statement is correct for this type of dressing?
A. The dressing will maintain a moist environment for the wound
B. The dressing should be allowed to dry out before removal
C. A gauge dressing should cover the transparent film dressing
D. The transparent film dressing should be tightly packed into the wound
Answer A

7. Which technique will maintain surgical asepsis?
A. Change the sterile field after sterile water is spilled on it
B. Put on sterile gloves and then open a container of sterile saline
C. Place a sterile dressing .5" from the edge of the sterile field
D. Clean the wound with a circular motion moving from outer circles toward the center
Answer A

8. Which intervention is performed first when changing a dressing or giving wound care?
A. Put on gloves
B. Wash hands thoroughly
C. Slowly remove soiled dressing
D. Observe the dressing for the amount, type, and odor of drainage
Answer B

9. When caring for a client who spends most of his time in bed, a turing schedule prevents the development of complications. Which schedule is best for most clients?
A. Turn every half hour
B. Turn every 1 to 2 hours
C. Turn once every 8 hours
D. Keep client on his back as much as possible
Answer B

10. A nurse is performing a skin assessment on a recently admitted client. Which factor is most important in planning care for the client?
A. Family history of pressure ulcers
B. Presence of exsisting pressure ulcers
C. Overall risk of developing pressure ulcers
D.Potential areas of pressure ulcer development
Answer B

11. A nurse educator is presenting a hygiene class to nursing students. Which statement by a nursing student indicates the need for further teaching?
A. The skin absorbs fluids
B. The skin is the body's first line of defense
C. The skin excretes waste products
D. The skin changes Vit D into a form the body can use
Answer D

12. The nurse is teaching a client how to care for his skin. What should the nurse instruct the client regarding sebum?
A. It is the most superficial layer of the skin
B. It is the oil secreted by the skin
C. It is a pouchlike depression from which a hair grows
D. It is the deepest layer of the skin
Answer B

13. An elderly client has a sore on the inside of his heal that he says won't heal. After noting varicosities and coarse discoloration around the sore, the nurse should suspect which finding?
A. Acute venous insufficiency
B. Chronic venous insufficiency
C. Acute arterial occlusive disease
D. Chronic arterial occlusive disease
Answer B

14. The physician orders a wet to dry dressing for a client who has a pressure ulcer with infected, necrotic tissue. What's the rationale for the treatment?
A. To prevent extension of the infection
B. To debride the wound
C. To keep the wound moist
D. To reduce pain
Answer B

15. A client has moist saline dressings applied to an open ulcer of the foot. Ten days after ulcer development, the wound should have which appearance?
A. Red, swollen tissue
B. Dry, crusted scab
C. Deep, wide keloid
D. Warm, painful tissue
Answer B
NCLEX Questions made Incredibly Easy
Medical-Surgical Reviews and Rationales

Increased Intracranial Pressure (ICP
1. Decreased level of consciousness
2. Behavior changes (restlessness, irritability)
3. Headache
4. Nausea and vomiting
5. Changes in speech pattern
6. Aphasia
7. Slurred speech
8. Change in sensorimotor status
9. Pupillary changes (dilate and nonreactive)
10. Cranial nerve dysfunction
11. Ataxia
12. Seizures
13. Cushing's triad
14. Severe hypertension
15. Widened pulse pressure
16. Bradycardia
17. Abnormal posturing (Decerebrate or Decorticate)
Iggy pg.1037

Do not lay patient with ICP in flat position.
Do not put patient with ICP in Trendelenburg position.
Do not turn head of a patient with ICP.


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