Unit 8 Chpt 19 and 38

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A patient who has an injury to the skin is most at risk for

infection with bacteria or viruses that may affect the person systemically

A person who has been exercising in a warm location is diaphoretic and his skin is flushed but cool. Nursing counsel in this situation should be for the person to

drink additional fluids to replace those lost through normal cooling

During an admission assessment to a skilled care facility, the nurse notes that a 76-year-old man is thin and unsteady on his feet and has several bruises on his arms and legs from falls. An appropriate hygiene goal for this patient is that

patient will shower or tub bathe with assist twice a week

In assessing the skin condition of an elderly patient, the nurse notes that, over the sacral area, there is a 2 3-cm area that is reddened, does not blanch around the perimeter, and is open at the center. The nurse correctly charts

"2 x3-cm reddened area on sacrum with open center. Does not blanch."

5.
An important factor to consider when assessing the hygiene needs of a patient is

patients may not have the same hygiene practices as the nurse.

What nursing interventions related to hygiene are appropriate for a patient who has had a recent stroke that caused right-sided paralysis (his dominant side) and inability to speak?

Encourage patient to use his nondominant hand to wash his face, brush his teeth, and perform other hygiene activities with assistance as necessary

Which of the following patients is most at risk for a pressure ulcer?

A 54-year-old overweight man who is unconscious from a stroke, has a urinary catheter in place, and has been incontinent of liquid stool since a feeding tube was placed

A patient has a quarter-sized blackened eschar on both heels surrounded by a 1- to 2-cm indurated reddened area. These are

pressure ulcers that cannot be accurately staged because of the eschar

A patient with a nursing diagnosis of Skin integrity, risk for impaired, is noted to have reddened areas on his right shoulder and hip when he is repositioned on a 2-hour turning schedule. The nurse should

reassess the area after 30 to 45 minutes for reactive hyperemia

To perform oral care for an unconscious patient, the nurse takes which action first?

Raise the bed to a comfortable working height and position the patient in a flat side-lying position

A patient who is recovering from repair of a fractured hip is still awake when the nurse makes her initial rounds at midnight. After assessing the patient, the nurse gives a back massage and straightens the bed covers. The patient states that he is much more relaxed. The nurse should

evaluate the patient after an hour to be sure he is sleeping

12.
A patient who has a dry, itchy dermatitis will most likely benefit from

an oatmeal or starch therapeutic bath with tepid water

A nurse is preparing to give a complete bath to an unconscious patient. After performing the standard steps done before any procedure, the nurse

washes each eye with a fresh area of the washcloth before washing the rest of the patient's face

When providing perineal care for an uncircumcised male patient, the nurse

retracts the foreskin, then clean the glans, being sure to replace it at the end of the procedure

15.
Providing oral care to a patient who has dentures includes

removing, cleaning, and storing the dentures in a labeled container at bedtime

16.
A patient who is NPO (not taking any food or fluids by mouth) because he is unconscious

needs to have his mouth swabbed to moisten and remove secretions every 2 hours

17.
It is most important for the nurse to write specific personal care plan modifications for the patient who

has an artificial eye and poor vision in the other

18.
A 20-year-old male patient is admitted in traction with a fractured femur after an auto accident. He has blood and dirt in his hair, which is long and tangled. It is most appropriate for the nurse to

remove tangles by using alcohol or water on small sections of hair, holding the hair between the scalp and the area she is brushing or combing

19.
When the nurse is assisting a male patient to shave his face, it is most important for her to

check whether a safety razor can be used or whether it is contraindicated.

A nurse is caring for a patient who is wearing contact lenses. If the patient cannot care for the lenses himself, and the nurse has difficulty removing a hard lens by hand, it is correct for the nurse to

use a lens suction cup to remove the lens

During the provision of oral care to an unconscious patient, the nurse uses suction primarily to

prevent fluids from collecting in the patient's mouth and being aspirated

A patient with insulin-dependent diabetes has a right below-the-knee amputation. What modification of his personal care is noted as most important

The patient's left foot should be soaked and gently dried, but his toenails should not be cut

A nurse notes that her patient has an area of red skin that does not blanch with fingertip pressure. The nurse documents this finding as a stage

I pressure ulcer

A nurse notes that her patient has an area of partial-thickness skin loss involving the epidermis. It has the appearance of a blister, and the area surrounding the damaged skin feels warmer. The nurse documents this finding as a stage

II pressure ulcer

A nurse notes that her patient has an area of full-thickness skin loss with an area that looks like a deep crater and extends to the fascia. The patient's subcutaneous tissue is necrotic. The patient also has a bacterial infection and there is damage to the surrounding tissue. The nurse documents this finding as a stage

III pressure ulcer.

A nurse notes that her patient has an area of full-thickness skin loss with extensive tissue necrosis and a widespread infection. The ulcer appears wet and oozing. The nurse documents this finding as a stage

IV pressure ulcer

One of the facility's unlicensed assistive personnel (UAPs) asks the nurse if she can use a safety razor to shave a patient. The nurse would advise the UAP to use a safety razor on which of the following patients?

A patient who is unable to shave himself

A nurse is instructing a nursing student regarding prevention of pressure ulcers. The nurse would recognize further instruction is warranted when the nursing student states, "I will

position the patient directly on the trochanter."

Which piece of data is part of assessment findings for a patient who has inflammation at the site of an injury?

Swelling

The nurse is taking care of a postsurgical patient and notes the incision is clean and dry, with sutures intact. The wound is healing by

primary intention

31.
A patient who is hospitalized after a motorcycle accident has areas of skin that were scraped away when he was thrown to the ground. The best term to use to describe this type of wound when documenting is

abrasions

surgical incision is beginning to have thick, creamy yellow drainage that has an odor. The drainage can best be described as

purulent

A patient who is admitted to the hospital for surgery is immunocompromised. This patient has an increased risk for

nosocomial infection

A nurse is assessing a surgical patient admitted a few hours ago, and a main concern is internal hemorrhage. The clinical signs that indicate this problem are

restlessness, rising pulse, and falling blood pressure

While a nurse is changing a surgical dressing, which nursing action puts the patient at increased risk for wound infection

Letting hair fall forward from the face

A nurse is ambulating a patient in the hall a few days after abdominal surgery and the patient says, "I think something just let go." Which action should the nurse take first?

Lie the patient in a supine position

patient who underwent removal of a breast must be discharged home with a Jackson-Pratt wound drain in place. As the patient demonstrates the procedure for emptying it, the nurse should correct her if she

uses one alcohol wipe to clean both the spout and the plug

A patient needs to have a nonadherent dressing applied to a wound. Which dressing material is most appropriate to use?

Telfa

A patient with an abdominal dressing requires frequent dressing changes but is beginning to show skin irritation from repeated tape removal. Which item would be most beneficial for this patient?

Montgomery straps

A nurse is repositioning a patient and notices a stage I pressure ulcer developing. Which product should be applied

Thin film dressing

A patient has a flat hemorrhagic spot on the skin of the arm. The nurse suspects it occurred because of trauma from bumping against the side rail of the bed. The nurse should document that this patient has a(n)

ecchymosis

The nurse has an order to perform a dry sterile dressing change for an assigned patient. It is most important to assess this patient for an allergy to

tape.

A patient is due for a wound dressing change for a horizontal lower abdominal incision. In which direction should the nurse pull to remove the tape from the old dressing?

From each of the four sides toward the wound

A nurse has an order to apply a hydrocolloid dressing to a skin ulcer. Which is best to use to prepare the skin around the border of the wound?

Skin prep pads

The nurse is changing a wet-to-dry normal saline dressing for a patient with an ulcer on the heel. When trying to remove the old dressing, it sticks to the wound bed. Which action should the nurse take?

Add normal saline to loosen it

A nurse has an order to perform a right eye irrigation. After obtaining an irrigation set with a piston syringe, the patient should be positioned

supine with the head tilted toward the affected eye

A patient has an order for a warm water soak to the foot. The nurse should plan to leave the foot in the water for

15 to 20 minutes

A patient with a high fever has been placed on a hypothermia blanket. The nurse should monitor for which clinical sign that could lead to a rise in the patient's temperature?

Shivering

Which of the following are main functions of the skin

protection, excretion, sensation, and secretion

Which of the following changes in the integumentary system are part of the normal aging process?

Hair becomes thin and grows more slowly
Skin is more fragile because of loss of collagen fibers
Skin wrinkles and sags

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