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Exhibits

The nurse reviews the client's data.

After collaboration with the wound care nurse, which intervention(s) should the primary nurse perform to reduce risk of skin injury? Select all that apply.

Apply a zinc based cream with brief changes

Apply powder to the perineum

Provide a donut shaped pillow to sit on

Use an antimicrobial soap to clean skin

Place a foam pad on the bed

Ensure the client slides up in bed on their own

Two person assist to move up in bed using slide sheet

Elevate the head of bed above 30 degrees

Request a physical therapy consult

Answer and Explanation

Correct Answer : A,E,G,I

A. Apply a zinc-based cream with brief changes. Zinc-based creams create a protective barrier against moisture and irritation from incontinence. This helps prevent skin breakdown by reducing the effects of prolonged exposure to urine and stool.
B. Apply powder to the perineum. Powder can cause clumping when mixed with moisture, increasing friction and leading to skin irritation. It is not the preferred method for preventing skin breakdown in incontinent patients.
C. Provide a donut-shaped pillow to sit on. Donut-shaped pillows create pressure points around the edges, which can worsen pressure injuries rather than prevent them. A pressure-relieving cushion is a better alternative.
D. Use an antimicrobial soap to clean skin. Harsh soaps can strip the skin of its natural protective oils, leading to dryness and irritation. A mild, pH-balanced cleanser is recommended for skin care.
E. Place a foam pad on the bed. Foam pads help redistribute pressure and reduce friction, lowering the risk of pressure injuries for patients who have limited mobility and spend extended time in bed.
F. Ensure the client slides up in bed on their own. Allowing the client to slide in bed increases friction and shearing forces, leading to skin breakdown. Assisted repositioning is necessary to prevent injury.
G. Two-person assist to move up in bed using a slide sheet. Using a slide sheet with assistance minimizes friction and shear, which are significant contributors to pressure ulcers. This method helps protect fragile skin.
H. Elevate the head of the bed above 30 degrees. Elevating the bed above 30 degrees increases pressure on the sacrum and coccyx, heightening the risk of skin breakdown. A lower elevation is preferred unless contraindicated.
I. Request a physical therapy consult. A physical therapy consult can help improve mobility, strength, and positioning techniques, reducing prolonged pressure on vulnerable areas and promoting skin integrity.

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

A. Scrambled eggs with roasted peppers and onions, lean ham, and toast. While peppers and onions provide antioxidants, the presence of processed meat (ham) increases the risk of some cancers, particularly colorectal cancer, due to nitrates and preservatives.
B. Pancakes with blueberries and maple syrup, and a turkey sausage patty. Blueberries are rich in antioxidants, which can help reduce cancer risk, but pancakes with syrup are high in refined carbohydrates and added sugars, which may contribute to inflammation and increased cancer risk.
C. Oatmeal with raisins and nuts, with skim milk and 1/2 grapefruit. Oatmeal contains fiber, which helps reduce the risk of colorectal cancer. Raisins and nuts provide antioxidants, while grapefruit is high in vitamin C, which supports immune function and may help protect against some cancers. This is the best balanced meal with cancer-protective nutrients.
D. Poached egg, bacon, biscuit, and canned peaches in light syrup. Bacon is a processed meat linked to an increased risk of colorectal cancer. Biscuits are refined carbohydrates, and canned peaches in syrup contain added sugars, which can contribute to inflammation and chronic disease risk.

A. To serve as sensory receptors and transmitters for the sense of touch. B. To anchor the epidermis to the dermis skin layer. C. To provide skin pigmentation as protection from the sun's ultraviolet rays. D. To produce a tough, fibrous structural protein for skin protection.

Correct Answer is D

Explanation

A. To serve as sensory receptors and transmitters for the sense of touch. Merkel cells, not keratinocytes, function as sensory receptors in the skin, particularly for touch perception.

B. To anchor the epidermis to the dermis skin layer. Hemidesmosomes and basement membrane proteins help anchor the epidermis to the dermis, not keratinocytes.

C. To provide skin pigmentation as protection from the sun's ultraviolet rays. Melanocytes, not keratinocytes, produce melanin, which provides skin pigmentation and protects against UV radiation.

D. To produce a tough, fibrous structural protein for skin protection. Keratinocytes are the primary cells of the epidermis and produce keratin, a strong, fibrous protein that provides structure, durability, and waterproofing to the skin. They also play a role in wound healing and immune defense.

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Exhibits The nurse reviews the client's data. After collaboration with the wound care nurse, which intervention(s) should the primary nurse perform to reduce risk of skin injury? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is conducting a nutritional class on foods that have been linked to help decrease the development of some forms of cancer. Which meal selection is the best choice to help reduce the risk of some cancers?

Correct Answer is C

Explanation

Which is the function of the keratinocytes, a type of skin cell?

Correct Answer is D

Explanation

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Exhibits The nurse reviews the client's data. After collaboration with the wound care nurse, which intervention(s) should the primary nurse perform to reduce risk of skin injury? Select all that apply.

After reviewing the history of a group of clients, which client should the nurse identify as having the greatest risk for cancer?

The nurse is teaching a health promotion class for adults about the effects of sun exposure on skin. Which statement about the function of collagen is correct?

Exhibits

The nurse reviews the client's data.

After collaboration with the wound care nurse, which intervention(s) should the primary nurse perform to reduce risk of skin injury? Select all that apply.