Exam 5 Flashcards

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created 2 years ago by kiol223
ATI Fundamentals for Nursing (edition 10.0) Pressure Ulcers, Wounds, and Wound Management, pp.341-348
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Apply steady pressure using a 35 ml syringe and 19-gauge needle .



ex of med for impedigo

amoxicillin, bactracin (topical)


meds for pediculicide

permethrin nix elimite acticin


what other treatment for candida

mouth wash nystatin or oral if in the gi


zole =

cadida treament


Known as moniliasis



Pale ischemic base, well-defined edges usually found on toes, heels, lateral malleoli

Arteriosclerosis, diabetes


vitamin c

delays formation of collagen


no zinc

impairs epithelization


The nurse caring for a patient with a healing Stage III pressure ulcer notes that the wound is clean and granulating. Which health

care provider’s order will the nurse question?

a. Use a low-air-loss therapy unit.

b. Irrigate with Dakin’s solution.

c. Apply a hydrogel dressing.

d. Consult a dietitian.



The nurse is completing an assessment on a patient who has a Stage IV pressure ulcer. The wound is odorous with a drain is

currently in place. Which statement by the patient indicates issues with self-concept?

a. “I am so weak and tired. I just want to feel better.”

b. “I been thinking I will be ready to go home early next week.”

c. “I really need a bath and linen change right; I feel so awful.”

d. “I am hoping there will be something good to eat for my dinner tonight.”



Upon entering the room of a patient with a healing Stage III pressure ulcer, the nurse notices an odor and observes a purulent

discharge, along with increased redness at the wound site. What action should the nurse give priority to?

a. Completing a head-to-toe assessment, including current treatment, vital signs, and

laboratory results

b. Notifying the health care provider by utilizing Situation, Background,

Assessment, and Recommendation (SBAR)

c. Consulting the wound care nurse about the change in status and the potential for


d. Conferring with the charge nurse about the change in status and the potential for




controlling bleeding with vasoconstriction, retraction of blood vessels, fibrin accumulation and clot formation.

inflammatory stage


macrophages engulf microorganisms and cellular debris in ________phase



A child has small red macules and vesicles that become pustules around the childs mouth and cheek. Older lesions are crusted and honey-colored. What should the nurse teach the parents about this condition?

a. Keep the child home from school for 24 hours after starting antibiotics.

b. Clean the rash vigorously with Betadine three times a day.

c. Notify the physician for any itching.

d. Keep the child home from school until the lesions are healed.



What should the parents of an infant with thrush (oral candidiasis) be taught about medication admin?

a. Give nystatin suspension with a syringe without a needle.

b. Apply nystatin cream to the affected area twice a day.

c. Give nystatin before the infant is fed.

d. Swab nystatin suspension onto the oral mucous membranes after feedings.



Parents of a child with lice infestation should be instructed carefully in the use of anti lice products because of which potential side effect?

a. Nephrotoxicity

b. Neurotoxicity

c. Ototoxicity

d. Bone marrow depression



When changing an infant’s diaper, the nurse notices small bright red papules with satellite lesions on the perineum,, anterior thigh, and lower abdomen. This rash is characteristic of

a. candidiasis.

b. irritant contact dermatitis.

c. intertrigo.

d. seborrheic dermatitis.



The depth of a burn injury may be classified as

a. localized or systemic.

b. superficial, superficial partial thickness, deep partial thickness, or full thickness.

c. electrical, chemical, or thermal.

d. minor, moderate, or major.



What best describes a full-thickness (third-degree) burn?

a. Erythema and pain

b. Skin showing erythema followed by blister formation

c. Destruction of all layers of skin evident with extension into subcutaneous tissue

d. Destruction injury involving underlying structures such as muscle, fascia, and bone



Which is an important nursing consideration when caring for a child with impetigo?

a. Apply topical corticosteroids to decrease inflammation

b. Carefully remove dressings so as not to dislodge undermined skin, crusts, and debris

c. Carefully wash hands and maintain cleanliness when caring for an infected child

d. Examine child under a Wood lamp for possible spread of lesions



Impetigo ordinarily results in

a. no scarring

b. pigmented spots

c. slightly depressed scars

d. atrophic white scars



The skin condition commonly known as “warts” is the result of an infection by which organism

a. Bacteria

b. Fungus

c. Parasite

d. Virus



A nurse is instructing parents on the treatment of pediculosis (head lice). Which should the nurse include in the teaching plan?

a. Retreat the hair and scalp with a pediculicide in 7 to 10 days.

b. Items that cannot be washed should be dry cleaned or sealed in plastic bags for 2 to 3 weeks.

c. Combs and brushes should be boiled in water for at least 10 minutes.
d. all



The patient diagnosed with athlete’s foot (tinea pedis) states that he is relieved because it is only athlete’s foot, and it can be treated

easily. Which information about this condition should the nurse consider when formulating a response to the patient?

a. It is contagious with frequent recurrences

b. It is most helpful to air-dry feet after bathing.

c. It is treated with salicylic acid

d. It is caused by lice.



Which action by the nurse will be the most important for preventing skin impairment in a mobile patient with local nerve damage?

a. Insert an indwelling urinary catheter.

b. Limit caloric and protein intake.

c. Turn the patient every 2 hours.

d. Assess for pain during a bath



The nurse is caring for a patient who has undergone surgery for a broken leg and has a cast in place. What should the nurse do to prevent skin impairment?

a. Assess surfaces exposed to the edges of the cast for pressure areas.

b. Keep the patient’s blood pressure low to prevent overperfusion of tissue.

c. Do not allow turning in bed because that may lead to re-dislocation of the leg.

d. Restrict the patient’s dietary intake to reduce the number of times on the bedpan.



The nurse caring for a patient who is immobile frequently checks for impaired skin integrity. What is the rationale for the nurse’s


a. Inadequate blood flow leads to decreased tissue ischemia.

b. Patients with limited caloric intake develop thicker skin.

c. Pressure reduces circulation to affected tissue

d. Verbalization of skin care needs is decreased.



When providing hygiene for an older-adult patient, the nurse closely assesses the skin. What is the rationale for the nurse’s action?

a. Outer skin layer becomes more resilient.

b. Less frequent bathing may be required

c. Skin becomes less subject to bruising.

d. Sweat glands become more active.



The nurse is bathing a patient and notices movement in the patient’s hair. Which action will the nurse take

a. Use gloves to inspect the hair

b. Apply a lindane-based shampoo immediately

c. Shave the hair off of the patient’s head

d. Ignore the movement and continue



A nurse is assessing a patient’s skin. Which patient is most at risk for impaired skin integrity

a. A patient who is afebrile

b. A patient who is diaphoretic

c. A patient with strong pedal pulses

d. A patient with adequate skin turgor



The nurse is teaching the parents of a child who has head lice (pediculosis capitis). Which information will the nurse include in the

teaching session?

a. Treatment is use of regular shampoo.

b. Products containing lindane are most effective.

c. Head lice may spread to furniture and other people.

d. Manual removal is not a realistic option as treatment.



The nurse is caring for a patient with cognitive impairments. Which actions will the nurse take during AM care? (Select all that


a. Administer ordered analgesic 1 hour before bath time.

b. Increase the frequency of skin assessment.

c. Reduce triggers in the environment.

d. Keep the room temperature cool.

e. Be as quick as possible.



The wound care nurse is monitoring a patient with a Stage III pressure ulcer whose wound presents with healthy tissue. How

should the nurse document this ulcer in the patient’s medical record?

a. Stage I pressure ulcer

b. Healing Stage II pressure ulcer

c. Healing Stage III pressure ulcer

d. Stage III pressure ulcer



_________is red, moist tissue composed of new blood vessels, the presence of which indicates progression toward healing



Soft yellow or white tissue is characteristic of _______—a substance that needs to be removed for the wound to heal.



____________is indicative of an infection and will need to be resolved for the wound to heal.

purulent drainage


wound involving loss of tissue such as a _______ or a pressure ulcer or laceration heals by secondary intention.



Which finding will alert the nurse to a potential wound dehiscence?

a. Protrusion of visceral organs through a wound opening

b. Chronic drainage of fluid through the incision site

c. Report by patient that something has given way

d. Drainage that is odorous and purulent



A nurse is caring for a patient with a wound. Which assessment data will be most relevant with regard to wound healing?

a. Muscular strength assessment

b. Pulse oximetry assessment

c. Sensation assessment

d. Sleep assessment