ATI LPN
Test Bank for Medical Surgical Nursing: Concepts for Interprofessional Collaborative Care 10th Edition
Chapter 25 Questions
Question 1 of 5
A nurse teaches a client who has very dry skin. Which statement should the nurse include in this clients education?
Correct Answer: D
Rationale: The client should bathe in warm water for at least 20 minutes and then apply lotion immediately because this will keep the moisturizer in the skin. Just using moisturizer will not be as helpful because the moisturizer is not what dehydrates the skin, it is the water. Bathing in warm water will rehydrate skin more effectively than a cold shower, and antimicrobial soaps are actually more drying than other kinds of soap.
Question 2 of 5
A nurse assesses clients on a medical-surgical unit. Which client is at greatest risk for pressure ulcer development?
Correct Answer: C
Rationale: Being immobile and being incontinent are two significant risk factors for the development of pressure ulcers. The client with pneumonia does not have specific risk factors. The young client who has a fractured leg and the client who needs assistance with ambulation might be at moderate risk if they do not move about much, but having two risk factors makes the 65-year-old the person at highest risk.
Question 3 of 5
When transferring a client into a chair, a nurse notices that the pressure-relieving mattress overlay has deep imprints of the clients buttocks, heels, and scapulae. Which action should the nurse take next?
Correct Answer: C
Rationale: Bottoming out, as evidenced by deep imprints in the mattress overlay, indicates that this device is not appropriate for this client, and a different device or strategy should be implemented to prevent pressure ulcer formation.
Question 4 of 5
A nurse cares for a client who has a deep wound that is being treated with a wet-to-damp dressing. Which intervention should the nurse include in this clients plan of care?
Correct Answer: A
Rationale: Wet-to-damp dressings are changed every 4 to 6 hours to provide maximum debridement. The wound should be assessed each time the dressing is changed. Dry gauze dressings should be changed when the outer layer becomes saturated. Synthetic dressings can be left in place for extended periods of time but need to be changed if the seal breaks and the exudate leaks.
Question 5 of 5
A nurse is caring for a client who has a pressure ulcer on the right ankle. Which action should the nurse take first?
Correct Answer: D
Rationale: A client with an ulcer on the foot should be assessed for interruption in arterial flow to the area. This begins with the assessment of pulses and color and temperature of the skin. The nurse can also assess for pulses noninvasively with a Doppler flowmeter if unable to palpate with fingers. Tests to determine nutritional status and risk assessment would be completed after the initial assessment is done. Wound cultures are done after it has been determined that drainage, odor, and other risks for infection are present. Elevation of the foot is appropriate after assessment of arterial flow to the area.