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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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Correct Answer is ["B","D","E"]

Explanation

A. Explain that the child is likely to grow into her weight. This is incorrect because a BMI at the 85th percentile indicates that the child is overweight. Without intervention, the risk of continued excess weight gain and future obesity increases.
B. Obtain the child's 3-day diet history based on the mother's input. Assessing the child's dietary habits helps identify potential areas for improvement, such as reducing sugary drinks or increasing fruit and vegetable intake. Understanding the child’s nutrition is essential for developing a healthy eating plan.
C. Tell the mother that girls hit their growth spurt before boys so eating more is expected. While girls do experience growth spurts earlier than boys, this does not justify excessive weight gain. Encouraging healthy eating and physical activity is more appropriate than assuming the child will "grow out of it."
D. Inquire as to whether or not the school has a physical education program. School-based physical activity plays an important role in weight management. If the school lacks a structured program, additional strategies for physical activity should be explored.
E. Determine the child's usual physical activity pattern. Assessing the child’s activity level helps identify if sedentary behaviors (e.g., excessive screen time) are contributing to weight gain. Encouraging regular physical activity is a key part of managing childhood obesity.

A. Serum blood glucose 185 mg/dL (10.2 mmol/L) B. Temperature 98.8° F (37.1° C) C. White blood cell count 11.2 x 103/μL (11.2 x 109/L) D. Capillary refill greater than 3 seconds bilateral lower extremities E. Bilateral lower extremities skin warm, dry, and pink F. Pain 2 on a 0 to 10 pain scale, bilateral lower legs described as neuropathic

Correct Answer is ["B","E","F"]

Explanation

A. Serum blood glucose 185 mg/dL (10.2 mmol/L) (Incorrect): Although lower than the previous reading, it is still elevated, which can impair healing and increase the risk of infection recurrence.
B. Temperature 98.8°F (37.1°C) (Therapeutic Response): A return to a normal temperature indicates resolution of systemic infection. Fever is a sign of active infection, so its absence suggests improvement.
C. White blood cell count 11.2 x 10³/μL (11.2 x 10⁹/L) (Incorrect): This is slightly elevated, which may indicate residual inflammation or infection. A further decrease would be expected for full resolution.
D. Capillary refill greater than 3 seconds bilateral lower extremities (Incorrect): Delayed capillary refill suggests impaired circulation, which is not an indicator of a fully therapeutic response.
E. Bilateral lower extremities skin warm, dry, and pink (Therapeutic Response): Improved skin condition suggests reduced inflammation, better circulation, and healing of the cellulitis-affected area.
F. Pain 2 on a 0 to 10 pain scale, bilateral lower legs described as neuropathic (Therapeutic Response): Pain related to cellulitis typically improves with treatment. If the remaining pain is neuropathic, it suggests resolution of the acute infection.

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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

Correct Answer is ["B","D","E"]

Explanation

Exhibits The client is seen for a 1 week follow up appointment. The nurse is evaluating the response to the treatment for cellulitis. Select the 3 findings consistent with a therapeutic response to interventions.

Correct Answer is ["B","E","F"]

Explanation

The nurse is visiting an older adult client who is homebound. Which finding about the client's nutritional status requires additional follow- up?

The nurse is caring for a client who has been diagnosed with malnutrition. Which finding supports the medical diagnosis? Reference Range: Body mass index (BMI) [18 to 24.9 kg/m3]

The nurse is assessing a client's skin and notices a raised nodule on the right forearm that is tender and filled with purulent secretions. The healthcare provider diagnosed the abscess as a furuncle. Which pathological etiology places the client at risk for the development of a furuncle?

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

Which test for HIV is used primarily as a confirmatory test rather than a generalized screening test?

Exhibits Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and to parameters the nurse should monitor to assess the client's progress.

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.