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The day following surgery, the nurse notes bloody drainage on the dressing. The nurse will record this drainage as
When the nurse discovers that the gauze dressing has adhered to the wound, the nurse should
Moisten the dressing with sterile water
Because the physician has not ordered a dressing change for a draining wound, the nurse should assess the amount of drainage by
Circling and dating the outline of the exudates on the dressing
When the nurse assesses that blood and fluid flow into the vascular space and produce edema, erythema, heat, and pain, the nurse is aware that the phase of healing is
In an attempt to keep the patient comfortable during a dressing change, the nurse may administer an analgesic
30 minutes before the change
When there is sustained skin pressure, especially over bony prominences, pressure ulcers may form due to
Collapse of the blood vessels
To meet the needs of an unconscious patient with a risk for skin impairment, the nurse will plan to have the patient's position changed every
The nurses assesses a red blister over the right superior iliac area and documents this decubitus as a
The nursing assessment of a pressure ulcer includes size and depth, pain, odor, and color of tissue in order to evaluate
Whether improvement is occurring
The nurse is attempting to avoid a pressure ulcer for her bedrest patient by turning him every 2 hours and moving him to which favorable position?
30 degree lateral
When providing hand and foot care, the person best prepared to provide nail care for patients with extremely hard nails is the
When the nurse discovers a reddened area over the hip, the first assessment should be to
Press the area gently to assess for blanching
When the nurse is collecting a specimen for a wound culture, the specimen should never be collected from
A patient has generalized macular-papular skin eruptions and complains of severe pruritus. When the nurse administers his therapeutic bath, it is important to remember that
Using burrow solution helps promote healing
A patient, age 63, has cancer of the left breast. After a modified radical mastectomy, she has been receiving chemotherapy. Her grandson, who visited a few days ago, now has varicella (chickenpox). The nurse should observe her carefully for signs of
A patient has herpes zoster (shingles). A local antiinfective agent, which is useful in delaying the progression of herpetic diseases, was prescribed. This medication is
A patient has been sent home from work with pruritus and honey-colored crusts on his lower lip and chin. A probable diagnosis would be
A patient has an erythematous patch of vesicles on her scalp, and she complains of pain and pruritus. A diagnosis of tinea capitis is made. The causative organism is
A patient, age 46, reports to his physician's office with urticaria and papules on his hands and arms. He says, "It itches so badly." In assessing the patient, the nurse should gather data regarding recent
Changes in meds
A patient has been receiving penicillin, acetaminophen with codeine, and hydrochlorothiazide for 4 days. He now has a urinary tract infection. A sulfonamide has been prescribed to be taken three times per day. Several hours later, he complains of pruritus. The nurse observes a generalized erythema and rash. The most appropriate nursing intervention would be to hold
All meds, and notify the physician of the signs and symptoms
A patient has acne vulgaris. When the nurse explains this condition, it is most important to
Explore how this condition is affecting his self image
A 30-year-old African American had surgery 6 months ago. Her incisional site is now raised, indurated, and shiny. This tissue growth is most likely a(n)
A patient, age 37, sustained partial- and full-thickness burns to 26% of her body surface area. The greatest fluid loss resulting from her burns will usually occur
Within 12 hours after burn trauma
Most of the deaths from burn trauma in the emergent phase that require a referral to a burn center result from
A patient, age 26, is admitted to the burn unit with partial- and full-thickness burns to 20% of his body surface area as well as smoke-inhalation injury. Carbon monoxide intoxication secondary to smoke inhalation is often fatal because carbon monoxide
binds with hemoglobin in place of oxygen...
A nurse arrives at an accident scene where the victim has just received an electrical burn. The nurse's primary concern is
The likelihood of cardiac arrest...
A patient, age 27, sustained thermal burns to 18% of her body surface area. For the next 72 hours, the nurse will have to observe for the most common cause of burn-related deaths, which is
A duodenal ulcer may occur 8-14 days after severe burns. Usually, the first symptom is bright red emesis. Which condition matches this description?
A nurse is providing the occlusive method of treatment for a patient who is 52 years old with burns to her lower extremities. It would be important for the nurse to
Keep the room temperature at 85 F (24.4 C)
The nurse has initiated measures to promote suppuration of a carbuncle. Which of the following would indicate that these measures have been successful?
The area has begun to drain exudates...
A patient, age 20, is admitted with severe eczema. In planning the care for her, the nurse should plan to
Keep the skin well hydrated...
The nurse is caring for a 26-year-old patient who was burned 72 hours ago. He has partial-thickness burns to 24% of his body surface area. He begins to excrete large amounts of urine. The nurse should
Assess for signs of fluid overload
A patient, age 29, is diagnosed with genital herpes. She is receiving acyclovir (Zovirax). Which of the following would indicate a therapeutic response?
Decrease in pain
A female patient is seen by the school nurse because of flat lesions that are clear in the center with erythematous borders. In assessing a patient for tinea corporis, the nurse would check
A patient has been walking in the woods. He complains of severe pruritus. The nurse notes an erythematous area on his lower legs. The first nursing intervention for dermatitis venenata would be to
Wash area with copious amounts of water
The nurse is débriding a wound. It is important to débride the wound to
Prevent infection and promote healing
A patient has been admitted to the hospital with burns to his upper chest. The nurse notes singed nasal hairs. It would be important for the nurse to assess this patient frequently for
Which of the following may indicate a malignant melanoma in a nevus on a patient's arm?
Irregular border of the mole
A dark-skinned patient has been admitted to the hospital in severe respiratory distress. To determine whether the patient is cyanotic, the nurse uses what knowledge of skin assessment?
Cyanosis can be seen in the lips and mucous membranes of patients with dark skin
A patient developed a severe contact dermatitis of her hands, arms, and lower legs after spending an afternoon picking strawberries. She states that the itching is severe and she cannot keep from scratching. Which instruction by the nurse will be most helpful in managing the pruritus?
Use cool, wet dressings and baths to promote vasoconstriction
A patient is a 32-year-old woman whose mother recently died from malignant melanoma. She asks the nurse about what she can do to prevent the development of malignant melanoma in herself and her children. The best response by the nurse includes which information regarding risk factors for melanoma?
Avoid exposure to the sun and use protective measures when exposure occurs
Which of the following is a consequence of a congenital absence of eccrine glands?
Inability to regulate body temperature
What is the name of the thickening of the epidermis that develops in response to constant pressure or irritation?
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