Passpoint-Integumentary
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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