Download Medical Surgical Nursing 8th Edition by Ignatavicius Test Bank 2025 UPDATE and more Exams Nursing in PDF only on Docsity!
Medical Surgical Nursing 8 th Edition by
Ignatavicius Test Bank
The client has dry skin and a history of cardiovascular disease. Which is the best intervention for the nurse to teach the client? a. "Wear pajamas to cover your legs at night." b. "Avoid wearing stockings." c. "Increase your fluid intake to 3 L/day." d. "Bathe in warm water and then apply lotion immediately." - ANSWER>>ANS: D The client should bathe in warm water for at least 20 minutes and then apply lotion immediately because this will keep the moisture in the skin. Covering the legs at night will not increase moisture. Increasing fluid intake to 3 L/day would not be recommended for a client with a history of cardiovascular disease. Stockings may dry the skin, so the best intervention is to keep moisture in the skin with lotion. Which intervention will best assist the client with pruritus? a. "Avoid activities and environments that increase perspiration." b. "Drinking alcoholic beverages will decrease stimulation of the itch receptors." c. "Wear clothing to keep the skin warm." d. "Avoid immersing the affected areas in water." - ANSWER>>ANS: A Pruritus is exacerbated by poor skin hydration, increased skin temperature, perspiration, and vasodilation. Drinking alcoholic beverages will further dehydrate clients. Warm clothing will vasodilate, adding to dehydration. Warm baths are recommended, with lotion applied immediately afterward. Which precaution will the nurse teach the client with urticaria who is prescribed to take diphenhydramine (Benadryl)? a. "Avoid sun exposure." b. "Avoid alcoholic beverages." c. "Avoid aspirin or aspirin-containing drugs." d. "Avoid weight gain." - ANSWER>>ANS: B
Benadryl is an antihistamine that will decrease itching. For most people, diphenhydramine causes drowsiness. This side effect is intensified when alcohol also is consumed, placing the client at increased risk for injury and falling. Aspirin will not interact with this medication. Weight gain and sun exposure should not affect the administration of the drug. When changing the dressing on a partial-thickness wound, a nurse observes small, pale pink bumps within the wound bed. Which is the nurse's best action? a. Removing the bumps with a sterile scalpel b. Documenting and continuing current treatment c. Cleaning the wound vigorously, wiping off the bumps d. Culturing the wound and placing the client on contact precautions - ANSWER>>ANS: B The small, pale pink bumps are granulation tissue characteristic of new capillary bed growth, an indication of proper wound healing. The nurse should continue current treatment and assessments. Attempting to remove the bumps in any way can interfere with healing. Which nursing intervention is best for the nurse to use to enhance healing of a 1-week-old partial-thickness wound? a. Using papain-urea (Accuzyme) cream as ordered b. Restricting the client's fluid intake c. Covering the wound with an airtight dressing d. Applying hydrocortisone cream as ordered - ANSWER>>ANS: A The presence of necrotic tissue retards epithelialization and granulation development. Accuzyme is a cream that removes necrotic tissue. Restricting fluid and covering the wound will deprive the new tissue of nutrition and will not enhance healing. Hydrocortisone cream may decrease itching but will not enhance healing. Which is the priority nursing diagnosis for the client going home with a surgical wound on the coccyx that is to heal by second intention? a. Acute Pain b. Risk for Infection
b. Client who requires assistance with ambulation c. Older client with hypertension d. Incontinent client with limited mobility - ANSWER>>ANS: D The client who is confined to a chair has the most risk factors. Being immobile and incontinent are two significant risk factors for the development of decubiti. Which dressing choice will the nurse make to protect a heavily draining deep pressure ulcer? a. Wet to dry gauze b. Dry cotton gauze c. Alginate packing, dry gauze cover d. Hydrocolloidal transparent film cover - ANSWER>>ANS: C Alginates are highly absorbent materials that do not damage healthy tissue. They require a top dressing to stay in place. Because this wound is draining heavily, this is the best choice. A wet to dry gauze is not used for this type of ulcer. A transparent dressing would hold in the drainage. Dry cotton gauze would quickly become saturated. When getting a client up in a chair, the nurse notices that the pressure- relieving mattress overlay has deep imprints of the client's buttocks, heels, and scapulae. Which is the nurse's best action? a. Turning the mattress overlay to the opposite side b. This is expected occurrence c. Applying a different pressure-relieving device d. Reinforcing the overlay by placing cushions between the mattress - ANSWER>>ANS: C "Bottoming out," as evidenced by the 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. How often will the nurse change a transparent film dressing for protection of a small, clean, lightly draining wound? a. Every 8 to 12 hours
b. As soon as the dressing is dry c. When "strike through" has occurred d. When the seal breaks and exudate leaks - ANSWER>>ANS: D Transparent film dressings on a clean base can be left in place for days, until the seal is broken and exudate leaks. Which client is being treated effectively? a. Client with a transparent film dressing on a heavily draining wound b. Client with an alginate dressing on a heavily draining wound c. Client with a wet to dry dressing on a heavily draining wound d. Client with an Accuzyme dressing on a pink wound with no drainage - ANSWER>>ANS: B Alginate is a type of dressing that is highly absorbent. A transparent film would not soak up the drainage, a wet to dry dressing is not for heavily draining wounds, and Accuzyme is for the débridement of necrotic tissue, and is not needed on a pink wound without drainage. Which client is receiving appropriate treatment? a. A client with an ulcer and slight necrosis receiving whirlpool treatment b. A client with a draining sacral pressure ulcer receiving whirlpool therapy c. A client with sunburn and erythema soaking in warm water for 20 minutes d. A client with urticaria instructed to take warm showers twice a day - ANSWER>>ANS: A Necrotic tissue should be removed so that healing can take place. The whirlpool treatment can gently remove the necrosis. A draining wound would not be treated with whirlpool therapy. Warm water would not be recommended for a client with erythema. A client with urticaria would be instructed to use cool water to decrease inflammation and itching. A nurse observes a small opening that is draining purulent material on the skin over the trochanter area of a bedridden client. Which is the nurse's next best action? a. Probing for a larger pocket of necrotic tissue b. Applying a transparent film dressing
Elevation of the foot would impair the ability of arterial blood to flow to the area. Wound cultures are done after determining that there is drainage, odor, and other risks for infection. Tests to determine nutritional status and risk assessment would be completed after the initial assessment is done. Which finding puts a client at greatest risk for wound infection? a. Client who is immunocompromised b. Client with a deep wound c. Client with reddened skin d. Client with a deep wound - ANSWER>>ANS: A A compromised immune system puts a client at greatest risk for infection. Which intervention will the nurse perform first for a client with pruritus? a. Assessment of vital signs b. Elevation of legs c. Instructing client not to scratch d. Administration of pain medication - ANSWER>>ANS: C The first intervention is to instruct the client not to scratch. Scratching can lead to infection and open sores. The client could also soak in cool water, take antihistamines, or apply lotion. Which statement made by the caregiver of a home care client indicates a need for clarification regarding pressure ulcer prevention and treatment? a. "I help him shift his position every hour when he sits in the chair." b. "I massage his tail bone every morning when he gets up because it is red." c. "I apply lotion to his arms and legs every evening because they are so dry." d. "He drinks a nutritional supplement between meals to maintain his weight." - ANSWER>>ANS: B Massage of reddened areas over bony prominences such as the coccyx, or tail bone, is contraindicated because the pressure of the massage can cause damage to the skin and subcutaneous tissue layers.
Which dietary choice is best for a client who has been identified as being at risk for imbalanced nutrition and formation of pressure ulcers? a. Low-fat diet consisting primarily of whole grains and cereals, with vitamin supplements b. High-protein diet with vitamins and mineral supplements c. Vegetarian diet with increased caloric supplements d. Low-fat, low-cholesterol, low-carbohydrate diet - ANSWER>>ANS: B The preferred diet is high in protein to assist in wound healing and prevention of new wounds. Fat is also needed to ensure formation of cell membranes. A vegetarian diet would not provide fat and high levels of protein. Which client's wound will the nurse recommend for surgical management? a. Client with a stage II pressure ulcer with granulation b. Client with a stage III pressure ulcer with a foul odor c. Client with a stage IV pressure ulcer with necrotic tissue d. Client with a stage III pressure ulcer with decreased blood flow - ANSWER>>ANS: C A wound with necrotic tissue needs to be débrided. This can be done surgically. A client with a deep pressure ulcer or wound may also be a candidate for a muscle flap to close it. However, if there is not good blood flow to the area, the client would not be a candidate for grafting. Granulation is an indication that wound healing is occurring and no surgical intervention is necessary. A wound with a foul odor should be evaluated for infection by culturing the exudates Which client will the nurse see first to evaluate for wound infection? a. The client with a negative blood culture b. The client with thin serous drainage c. The client with a white blood cell count elevation d. The client with a decrease in wound size - ANSWER>>ANS: C A client with an elevated white count should be evaluated for sources of infection. Thin drainage, decrease in wound size, and negative cultures are not indications that the client may have an infection.
for an infection, but should be at lower risk for MRSA than the client admitted from the communal environment. Which nurse most was infected by a client? a. The nurse with an oral lesion determined to be herpes simplex virus 1 (HSV1) infection b. The nurse with herpetic whitlow of the fingertip c. The nurse with herpes zoster involving the right side of the body d. The nurse with postherpetic neuralgia - ANSWER>>ANS: B Herpetic whitlow is a form of herpes simplex infection that occurs in health care personnel who have come into contact with viral secretions. This can be spread to other clients as well, and precautions must be taken. HSV infection is most likely a recurring cold sore. Herpes zoster is caused by the reactivation of a virus dormant in the body. Postherpetic neuralgia occurs after an outbreak of herpes zoster and is not contagious. Which is the priority nursing intervention for the client during the first 24 hours after a skin graft procedure? a. Monitoring for detection of hemorrhage b. Monitoring of graft site to assess "take" of the newly grafted skin c. Repositioning the client every 2 hours to prevent pressure ulcer formation d. Performing interventions to prevent contracture development - ANSWER>>ANS: B The most serious common complication in the early postoperative period after skin grafting is failure to engraft. Hemorrhage is not a common complication post-skin grafting. Pressure ulcer formation and contracture development would not occur quickly after grafting. The home care client with a leg wound is unable to climb stairs to the second floor where the bathtub is located. Which is the nurse's best intervention? a. "I'll show you how to use a 35-mL syringe to cleanse the wound." b. "It is not necessary to clean this wound because it is not infected." c. "You can use the kitchen sink and clean tap water for this purpose."
d. "You will have to come to the hospital each day for hydrotherapy." - ANSWER>>ANS: A Mechanical débridement can be accomplished using the forceful ejection of tap water from a 35-mL syringe. Soaking in a tub is not essential. The client does not have to travel to the hospital. Which instruction is best for the nurse to teach the client who has a furuncle in his axilla? a. "Apply cortisone cream to reduce the inflammation." b. "Squeeze the lesion until it opens and all pus and other material are removed." c. "Keep your arm down against your side to close off the area and prevent spread." d. "Wash with antibacterial soap and apply warm compresses and antibiotic cream." - ANSWER>>ANS: D Cortisone cream reduces the inflammatory response but increases the infectious process. Squeezing the lesion may introduce infection to deeper tissue and cause cellulitis. Keeping the arm down increases moisture in the area and promotes bacterial growth. Cleansing and topical antibiotics can eliminate the infection. Warm compresses increase comfort and open the lesion, allowing better penetration of the topical antibiotic. The home care nurse is visiting an older adult client who has diabetes and "skinned his shin" yesterday. There is an intact scab over the abrasion and the skin around it is red, warm, and hard. Which is the nurse's best action? a. Teaching the client how to apply cold compresses to the area b. Lifting an area of scab to see if any exudate can be expressed c. Measuring the length and width of the red area d. Calling the health care provider for a prescription to treat cellulitis - ANSWER>>ANS: D The clinical manifestations indicate cellulitis, a bacterial tissue infection that can spread rapidly and deeply, especially in a client who is diabetic. Cold compresses would not be effective in allowing the lesion to heal.
Which question will the nurse ask to determine a possible trigger for the worsening of a client's psoriatic lesions? a. "Have you eaten a large amount of chocolate lately?" b. "Have you been under a lot of stress lately?" c. "Have you used a public shower recently?" d. "Have you been out of the country recently?" - ANSWER>>ANS: B Systemic factors, hormonal changes, psychological stress, medications, and general health factors can aggravate psoriasis. A nurse notes that the client who has been using psoralens-ultraviolet A (PUVA) therapy for psoriasis for 1 month has darkening of the skin. Which is the nurse's best action? a. Documenting the finding b. Instructing the client to reduce the dose c. Instructing the client to drink more water d. Instruct the client to apply cortisone cream - ANSWER>>ANS: A Darkening of the skin is an expected and normal response to the PUVA therapy. No other intervention is necessary. The client has an epidermal cyst behind the right ear. Why is surgical removal of this cyst indicated? a. Most cysts become chronically infected and painful. b. Epidermal cysts have a high rate of transformation to cancer. c. The client's glasses press against the cyst and cause discomfort. d. Unless surgically removed, the cyst could increase in size and compromise the client's hearing. - ANSWER>>ANS: C Therapy to remove an epidermal cyst is rarely indicated unless the client prefers that it be removed Which strategy will best prevent the spread of a fungal infection that is beneath a client's breasts? a. Moving the client into a private room b. Washing hands after caring for the client c. Wearing gloves when providing personal care d. Applying cortisone cream to lesions - ANSWER>>ANS: B
The organism that causes this infection lives on the skin of most adults. Good handwashing is all that is needed to prevent its spread to other people, although the client will need medication to clear her active infection and moisture management to prevent its recurrence. An African-American woman had a breast biopsy 1 year ago. The incision site is elevated, dark, and protruding. Which is the nurse's interpretation for these finding? a. The client has formed a keloid. b. There is a high probability that skin cancer has developed. c. The benign breast disease has undergone malignant transformation. d. Chronic inflammatory of deep infection has occurred. - ANSWER>>ANS: A A keloid is a benign, noninfectious, overgrowth of a scar from an excessive accumulation of collagen and ground substance after skin trauma. Although anyone can form a keloid, the propensity is more common among people with dark skin. This is a benign condition. A client has numerous skin lesions. Which one will the nurse evaluate first? a. Beige freckles on the backs of both hands b. Irregular blue mole with white specks on the lower leg c. Large cluster of pustules in the right axilla d. Raised, tubular, white, snake-like areas on the inner aspects of the wrists - ANSWER>>ANS: B This mole fits two of the criteria for being cancerous or precancerous: variation of color within one lesion, and an indistinct or irregular border. Melanoma is an invasive malignant disease with the potential for a fatal outcome. Freckles are a benign condition. Pustules could mean an infection, but it is more important to take care of the potentially cancerous lesion first. Which statement made by the client indicates correct knowledge about the causes and treatments of common warts? a. "Washing my hands more frequently will prevent the warts from coming back."
Isotretinoin has many side effects. It is a known teratogen and can cause severe birth defects. A pregnancy test is required before therapy is initiated and strict birth control measures must be used during therapy. The client has frostbite on one cheek. After the frostbite has thawed, a few small blisters appear in the area. Which action will the nurse take? a. Notifies the health care provider b. Leaves the blisters intact c. Applies ice or cold compresses to the area d. Breaks the blisters and applies a topical antibiotic - ANSWER>>ANS: B Blisters are left intact as a protective barrier to the injured skin beneath. Ice or cold compresses could extend the injury. It is not infected and a topical antibiotic is not necessary. The blisters should not be broken. Which characteristic regarding leprosy is true? a. There are only a few cases found in underdeveloped countries. b. Affected clients must be confined away from the general population. c. Continuous treatment with antibiotic agents is necessary. d. Because the disease has an autoimmune basis, the most effective treatment of leprosy involves immunosuppressive drugs. - ANSWER>>ANS: C Leprosy is a communicable disease caused by mycobacteria. It is present in most areas of the world, including the United States. It can be controlled with antibiotic therapy and does not require the client to be isolated. The client who has had a rhinoplasty is swallowing frequently and belching. Which action will the nurse take? a. Notifying the surgeon b. Raising the head of the bed c. Assisting the client with liquids d. Continuing to assess - ANSWER>>ANS: A Repeated swallowing followed by belching after rhinoplasty is a sign of postnasal bleeding. This sign should be reported immediately to the surgeon.
On assessment, the nurse notes a wound on the coccyx that is 3 2 2 cm. The epidermal and some of the dermal tissues are gone. The client reports pain when the nurse probes the wound with a cotton swab while assessing for undermining. The nurse charts this as what stage? a. Stage 1 b. Stage 2 c. Stage 3 d. Stage 4 - ANSWER>>ANS: B The criteria meet the definition of a stage 2 pressure sore. The nurse is prioritizing care to prevent pressure sores for a client who is immobilized. Which interventions are appropriate? (Select all that apply.) a. Placing a small pillow between bony surfaces b. Elevating the head of the bed to 45 degrees c. Limiting fluids and proteins in the diet d. Using a lift sheet to assist with repositioning e. Repositioning the client who is in a chair every 2 hours f. Keeping the heels off the bed surfaces g. Using a rubber ring to decrease sacral pressure when up in the chair - ANSWER>>ANS: A, D, F A small pillow decreases the risk for pressure between bony prominences, a lift sheet decreases friction and sheer, and heels have poor circulation and are at high risk for pressure sores, so they should be kept off hard surfaces. Head of the bed elevation more than 30 degrees increases pressure on the pelvic soft tissues. Fluids and proteins are important for maintaining tissue integrity. Clients should be repositioned every hour while sitting in a chair. A rubber ring impairs capillary blood flow, increasing the risk for a pressure sore. In preparation for a client being admitted with herpes zoster, what will the nurse do? (Select all that apply.) a. Prepares a room for reverse isolation b. Inventories the staff for a history of or vaccination for chickenpox c. Checks the admission orders for analgesia d. Chooses a roommate who also is immunosuppressed
