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Passpoint-Integumentary.
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  • Nursing Assessment

Passpoint-Integumentary.

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Document information

  • March 30, 2022
  • 65
  • 2022/2023
  • Exam (elaborations)
  • Questions & answers

Subjects

  • passpoint integumentary

Written for

  • Nursing assessment
All documents for this subject (9466)

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Question 1 See full question

When assessing a client who is incontinent for risk for developing a pressure ulcer, the nurse should note
which factor that can most alter tissue tolerance and lead to the development of a pressure ulcer?

You Selected:

 exposure to moisture

Correct response:

 exposure to moisture

Explanation:

Remediation:

Question 2 See full question

The nurse is assessing a hospitalized older client for the presence of pressure ulcers. The nurse notes
that the client has a 1 inch × 1 inch (3 cm x 3 cm) area on the sacrum in which there is skin breakdown as
far as the dermis. What should the nurse note on the medical record?

You Selected:

 stage I pressure ulcer

Correct response:

 stage II pressure ulcer

Explanation:

Remediation:

Question 3 See full question

Which factor is most important for the nurse to consider when determining the angle at which to insert
the needle for a subcutaneous injection?

You Selected:

 length of the needle

Correct response:

 amount of subcutaneous tissue

Explanation:

Remediation:

Question 4 See full question

During the first 48 to 72 hours of fluid resuscitation therapy after a major burn injury, the nurse should
monitor hourly which information that will be used to determine the IV infusion rate?

,You Selected:

 urine output

Correct response:

 urine output

Explanation:

Remediation:

Question 5 See full question

A nurse is preparing a discharge teaching plan for a client with atopic dermatitis. Which instruction
should the nurse include in her teaching plan?

You Selected:

 Use a topical skin moisturizer daily.

Correct response:

 Use a topical skin moisturizer daily.

Explanation:

Remediation:

Question 6 See full question

A client with deep partial-thickness and full-thickness burns on the arms receives autografts. Two days
later, the nurse finds the client doing arm exercises. The nurse provides additional client teaching
because these exercises may:

You Selected:

 dislodge the autografts.

Correct response:

 dislodge the autografts.

Explanation:

Remediation:

Question 7 See full question

A client has partial-thickness burns on both lower extremities and portions of the trunk. Which I.V. fluid
does the nurse plan to administer first?

You Selected:

 Lactated Ringer's solution

,Correct response:

 Lactated Ringer's solution

Explanation:

Remediation:

Question 8 See full question

The nurse is caring for an immune compromised client with a fungal infection of the scalp. What
recommendation should the nurse make to prevent future problems?

You Selected:

 Wash hair with a dandruff-preventing shampoo.

Correct response:

 Avoid sharing combs and brushes.

Explanation:

Remediation:

Question 9 See full question

A client has suffered a deep partial-thickness burn to the right arm from a high-voltage source of energy
that was not turned off while working on it. What is the priority nursing intervention in the acute phase
of care?

You Selected:

 A cardiac monitor should be used for at least 24 hours to anticipate the potential for cardiac
dysrhythmias.

Correct response:

 A cardiac monitor should be used for at least 24 hours to anticipate the potential for cardiac
dysrhythmias.

Explanation:

Remediation:

Question 10 See full question

A client in a semiprivate room is diagnosed with pediculosis corpus. A nurse will initiate treatment after
moving the client to another room. The client's roommate asks the nurse for information about the
client. What should the nurse say?

You Selected:

 "I'm sorry, but I can't share confidential information."

, Correct response:

 "I'm sorry, but I can't share confidential information."

Question 1 See full question

A female client is diagnosed with primary herpes genitalis. Which instruction should the nurse provide?

You Selected:

 "Apply acyclovir ointment to the lesions every 3 hours, six times per day for 7 days."

Correct response:

 "Apply acyclovir ointment to the lesions every 3 hours, six times per day for 7 days."

Explanation:

Remediation:

Question 2 See full question

A client who was bitten by a wild animal is admitted to an acute care facility for treatment of rabies.
Which type of isolation does this client require?

You Selected:

 Contact

Correct response:

 Contact

Explanation:

Remediation:

Question 3 See full question

Which instruction is the most important to give a client who has recently had a skin graft?

You Selected:

 Protect the graft from direct sunlight.

Correct response:

 Protect the graft from direct sunlight.

Explanation:

Remediation:

Question 4 See full question

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