A nurse is reinforcing teaching with a client about maintaining skin integrity to decrease the risk of infection. Which of the following instructions should the nurse include?

"Use a moisturizer on your skin after cleaning."

"Rub your skin firmly when cleaning."

"Wash your skin daily with hot water.”

"Allow your skin to air dry after bathing.”

Answer and Explanation

The Correct Answer is A

A. "Use a moisturizer on your skin after cleaning."
Moisturizers help maintain skin hydration and barrier function, reducing the risk of breakdown and infection.

B. "Rub your skin firmly when cleaning."
This can cause microabrasions and increase the risk of skin breakdown and infection.

C. "Wash your skin daily with hot water.”
Hot water can dry out the skin and compromise the skin barrier, increasing infection risk.

D. "Allow your skin to air dry after bathing.”
Patting the skin dry is better than air drying, which can lead to excessive dryness and irritation.

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Correct Answer is C

Explanation

A. A shallow, ruptured or intact skin blister without slough:
Describes a Stage 2 pressure ulcer.

B. Unbroken skin with un-blancheable erythema:
This is a Stage 1 pressure ulcer.

C. A deep crater without visible bone, tendon, or muscle:
Correct. This describes a Stage 3 pressure ulcer with full-thickness tissue loss and subcutaneous damage.

D. Full-thickness tissue loss extending to underlying support structures:
This describes a Stage 4 pressure ulcer.

A. Apply dry, sterile gauze dressings to affected areas. B. Prepare to administer acyclovir. C. Apply topical corticosteroids to the affected areas. D. Instruct family with a history of chickenpox that they should not visit the client.

Correct Answer is B

Explanation

A. Apply dry, sterile gauze dressings to affected areas
Shingles lesions are usually left open to air or covered with non-adherent dressings. Dry gauze may adhere to lesions and cause trauma.

B. Prepare to administer acyclovir
Acyclovir is an antiviral medication used to reduce severity and duration of herpes zoster (shingles) symptoms.

C. Apply topical corticosteroids to the affected areas
Topical corticosteroids are not recommended for herpes zoster as they can worsen viral infections.

D. Instruct family with a history of chickenpox that they should not visit the client
People who have had chickenpox are immune to varicella-zoster virus and can visit safely. Only individuals without prior exposure or vaccination should avoid contact.

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A nurse is reinforcing teaching with a client about maintaining skin integrity to decrease the risk of infection. Which of the following instructions should the nurse include?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

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Correct Answer is B

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