Chapter 15: Integumentary Problems

Question 1

Which actions will the nurse use when treating a client with a venous ulcer on the right lower leg? Select all that apply.

1. Position the right leg lower than the heart.
2. Use compression wraps consistently.
3. Administer analgesics before wound care.
4. Maintain a dry wound environment.
5. Encourage right ankle flexion exercises.
6. Clean wound with a nonirritating solution.

Answer 1

Ans: 2, 3, 5, 6
Current guidelines for promotion of venous ulcer healing suggest use of compression, appropriate analgesia, use of exercises to improve venous return, and wound cleansing with a non-irritating solution such as normal saline. The extremity should be elevated to promote venous return and decrease swelling. A moist environment encourages wound healing. Focus: Prioritization.

Question 2

After the nurse has performed a skin assessment on a recently admitted 19- year-old client, which finding is the highest priority to report to the health care provider?

1. Mole 2 mm in diameter on the chest
2. Tenting of the skin on the forearms
3. Patches of vitiligo around both eyes
4. Scattered brown macules on the face

Answer 2

Ans: 2
Tenting of the skin on younger clients may indicate dehydration and the need for oral or IV fluid administration. The other data will be recorded but do not require any rapid interventions. Focus: Prioritization.

Question 3

The home health nurse is caring for a client with a fungal infection of the toenails who has a new prescription for oral itraconazole. Which client information is most important to discuss with the health care provider (HCP) before administration of the itraconazole?

1. The client’s toenails are thick and yellow.
2. The client is embarrassed by the infection.
3. The client is also taking simvastatin daily.
4. The client is allergic to iodine and shellfish.

Answer 3

Ans: 3
The “azole” antifungal medications inhibit drug-metabolizing enzymes (when used orally or intravenously) and can lead to toxic levels of many other medications, including some commonly prescribed statins. Thick and yellow toenails are typical with fungal infections in this area, and clients may be embarrassed by the appearance of the nails, but antifungal treatment will improve the appearance of the nails. The client’s iodine allergy will be reported to the HCP but will not impact on use of itraconazole. Focus: Prioritization; Test Taking Tip: Be aware that the “azole” medications affect cytochrome P450, an enzyme system that is responsible for the metabolism of many medications. When a client is taking an azole, plan to check any newly prescribed medications for possible drug interactions that might lead to toxicity.

Question 4

The health care provider (HCP) prescribes permethrin application for all family members of a client who has scabies. Which client information will be most important for the nurse to discuss with the HCP before client teaching about the medication?

1. The client has a newborn infant.
2. Burrows are noted on the wrists.
3. The client and family are homeless.
4. Family members are asymptomatic.

Answer 4

Ans: 1
Although all family members (symptomatic or not) should be treated for scabies, permethrin is contraindicated in clients who are younger than 2 months of age because of concerns that the medication may be absorbed systemically. Burrows on the wrist are commonly seen with scabies. The client’s homelessness may affect teaching about how to launder clothes and linens but will not impact on use of permethrin for treating the scabies infestation. Focus: Prioritization.

Question 5

The nurse is caring for a client who has just had a squamous cell carcinoma removed from the face. Which action can be assigned to an experienced LPN/LVN?

1. Teaching the client about risk factors for squamous cell carcinoma
2. Showing the client how to care for the surgical site at home
3. Monitoring the surgical site for swelling, bleeding, or pain
4. Discussing the reasons for avoiding aspirin use for 1 week after surgery

Answer 5

Ans: 3
An LPN/LVN who is experienced in working with postoperative clients will know how to monitor for pain, bleeding, or swelling and will notify the supervising RN. Client teaching requires more education and a broader scope of practice and is appropriate for RN staff members. Focus: Assignment.

Question 6

The charge nurse in a long-term care (LTC) facility that employs RNs, LPNs/LVNs, and unlicensed assistive personnel (UAP) is planning care for a resident with a stage III sacral pressure ulcer. Which nursing intervention is best to assign to an LPN/LVN?

1. Choosing the type of dressing to be used on the ulcer
2. Using the Braden scale to assess for pressure ulcer risk factors
3. Assisting the client in changing position at frequent intervals
4. Cleaning and changing the dressing on the ulcer every morning

Answer 6

Ans: 4
LPN/LVN education and scope of practice includes sterile and nonsterile wound care. LPNs/LVNs do function as wound care nurses in some LTC facilities, but the choice of dressing type and assessment for risk factors are more complex skills that are appropriate to the RN level of practice. Assisting the client to change position is a task included in UAP education and would be more appropriate to delegate to the UAP. Focus: Assignment.

Question 7

The nurse has just received a change-of-shift report for the burn unit. Which client should be assessed first?

1. Client with deep partial-thickness burns on both legs who reports severe and continuous leg pain
2. Client who has just arrived from the emergency department with facial burns sustained in a house fire
3. Client who has just been transferred from the postanesthesia care unit after having skin grafts applied to the anterior chest
4. Client admitted 3 weeks ago with full-thickness leg and buttock burns who has been waiting for 3 hours to receive discharge teaching

Answer 7

Ans: 2
Facial burns are frequently associated with airway inflammation and swelling, so this client requires the most immediate assessment. The other clients also require rapid assessment or interventions but not as urgently as the client with facial burns. Focus: Prioritization.

Question 8

The nurse is performing a sterile dressing change for a client with infected deep partial-thickness burns of the chest and abdomen. List the steps in the order in which each should be accomplished.

1. Apply silver sulfadiazine ointment.
2. Obtain specimens for aerobic and anaerobic wound cultures.
3. Administer morphine sulfate 10 mg IV.
4. Débride the wound of eschar using gauze sponges.
5. Cover the wound with a sterile gauze dressing.

Answer 8

Ans: 3, 4, 2, 1, 5
Pain medication should be administered before changing the dressing because changing dressings for partial-thickness burns is painful, especially if the dressing change involves removal of eschar. The wound should be débrided before obtaining wound specimens for culture to avoid including bacteria that are skin contaminants rather than causes of the wound infection. Culture specimens should be obtained before the application of antibacterial creams. The antibacterial cream should then be applied to the area after débridement to gain the maximum effect. Finally, the wound should be covered with a sterile dressing. Focus: Prioritization.

Question 9

Which client is best for the nurse manager on the burn unit to assign to an RN who has floated from the oncology unit?

1. A 23-year-old client who has just been admitted with burns over 30% of the body after a warehouse fire
2. A 36-year-old client who requires discharge teaching about nutrition and wound care after having skin grafts
3. A 45-year-old client with infected partial-thickness back and chest burns who has a dressing change scheduled
4. A 57-year-old client with full-thickness burns on both arms who needs assistance in positioning hand splints

Answer 9

Ans: 3
A nurse from the oncology unit would be familiar with dressing changes and sterile technique. The charge RN in the burn unit would work closely with the float RN to provide partners to assist in providing care and to answer any questions. Admission assessment and development of the initial care plan, discharge teaching, and splint positioning in burn clients all require expertise in caring for clients with burns. These clients should be assigned to RNs who regularly work on the burn unit. Focus: Assignment.

Question 10

After the nurse performs a skin assessment on a 70-year-old new resident in a long-term care facility, which finding is of most concern?

1. Numerous striae are noted across the abdomen and buttocks.
2. All the toenails are thickened and yellow.
3. Silver scaling is present on the elbows and knees.
4. An irregular border is seen on a black mole on the scalp.

Answer 10

Ans: 4
Irregular borders and a black or variegated color are characteristics associated with malignant skin lesions. Striae and toenail thickening or yellowing are common in older adults. Silver scaling is associated with chronic conditions such as psoriasis and eczema, which may need treatment but are not as urgent a concern as the appearance of the mole. Focus: Prioritization.

Question 11

Which assessment finding calls for the most immediate action by the nurse?

1. Bluish color around the lips and earlobes
2. Yellow color of the skin and sclera
3. Bilateral erythema of the face and neck
4. Dark brown spotting on the chest and back

Answer 11

Ans: 1
A blue color or cyanosis may indicate that the client has significant problems with circulation or ventilation. Further assessment of respiratory and circulatory status is needed immediately to determine if actions such as administration of oxygen or medications are appropriate. The other data may also indicate health problems in major body systems, but potential respiratory or circulatory abnormalities are the priority. Focus: Prioritization.

Question 12

The nurse obtains this information about a 60-year-old client who has a
shingles infection. Which finding is of most concern?
1. The client has had symptoms for about 2 days.
2. The client has severe burning-type discomfort.
3. The client has not had the herpes zoster vaccination.
4. The client’s spouse is currently receiving cancer chemotherapy.

Answer 12

Ans: 4
Because exposure to clients with shingles may cause herpes zoster infection (including systemic infection) in individuals who are immune suppressed, teaching about how to prevent transmission and possible evaluation and treatment of the client’s spouse is needed. Antiviral treatment is most effective when started within 72 hours of symptom development. The client will need analgesics to treat the pain associated with shingles and may receive vaccination, but the biggest concern is possible infection of the client’s spouse. Focus: Prioritization.

Question 13

Which of these actions will the nurse take first for a client who has arrived in the emergency department with sudden-onset urticaria and intense itching?

1. Ask the client about any new medications.
2. Administer the prescribed cetirizine.
3. Apply topical corticosteroid cream.
4. Auscultate the client’s breath sounds.

Answer 13

Ans: 4
Because urticaria can be associated with anaphylaxis, assessment for clinical manifestations of anaphylaxis (e.g., respiratory distress, wheezes, or hypotension) should be done immediately. The other actions are also appropriate, but therapy will change if an anaphylactic reaction is occurring. Focus: Prioritization.

Question 14

A 22-year-old woman who has been taking isotretinoin to treat severe cystic acne makes all these statements while being seen for a follow-up examination. Which statement is of most concern?

1. “My husband and I are thinking of starting a family soon.”
2. “I don’t think there has been much improvement in my skin.”
3. “Sometimes I get nauseated after taking the medication.”
4. “I have been experiencing a lot of muscle aches and pains.”

Answer 14

Ans: 1
Because isotretinoin is associated with a high incidence of birth defects, it is important that the client stop using the medication at least 1 month before attempting to become pregnant. Nausea and muscle aches are possible adverse effects of isotretinoin that would require further assessment but are not as urgent as discussing the fetal risks associated with this medication. The client’s concern about whether treatment is effective should be addressed, but this is a lower priority intervention. Focus: Prioritization.

Question 15

A client is scheduled for patch testing to determine allergies to several substances. Which action associated with this test should the nurse delegate to unlicensed assistive personnel (UAP) working in the allergy clinic?

1. Explaining the purpose of the testing to the client
2. Examining the patch area for evidence of a reaction
3. Scheduling a follow-up appointment for the client in 2 days
4. Monitoring the client for anaphylactic reactions to the testing

Answer 15

Ans: 3
Scheduling a follow-up appointment for the client is within the legal scope of practice and training for the UAP role. Client teaching, assessment for positive skin reactions to the test, and monitoring for serious allergic reactions are appropriate to the education and practice role of licensed nursing staff. Focus: Delegation.

Question 16

The nurse is planning hospital discharge teaching for four clients. For which client is it most important to instruct about the need to use sunscreen?

1. A 32-year-old client with pneumonia who has a new prescription for doxycycline
2. A fair-skinned 55-year-old client with psoriasis who works outside for 8 hours daily
3. A dark-skinned 62-year-old client who has had keloids injected with hydrocortisone
4. A 78-year-old client with a red, pruritic rash caused by an allergic reaction to penicillin

Answer 16

Ans: 1
Systemic use of tetracyclines such as doxycycline is associated with severe photosensitivity reactions to ultraviolet (UV) light. All individuals should be taught about the potential risks of overexposure to sunlight or other UV light, but the client taking doxycycline is at the most immediate risk for severe adverse effects. Focus: Prioritization.

Question 17

The home health nurse is caring for a 72-year-old client who has a stage II pressure ulcer, with risk factors of poor nutrition, bladder incontinence, and immobility. Which nursing action should be delegated to the unlicensed assistive personnel (UAP)?

1. Telling the client and family to apply the skin barrier cream in a smooth, even layer
2. Completing a diet assessment and suggesting changes in diet to improve the client’s nutrition
3. Reminding the family to help the client to the commode every 2 hours during the day
4. Evaluating the client for improvement in documented areas of skin breakdown or damage

Answer 17

Ans: 3
Although it is not appropriate for UAPs to plan or implement initial client or family teaching, reinforcement of previous teaching is an important function of UAPs (who are likely to be in the home on a daily basis). Teaching about medication use, nutritional assessment and planning, and evaluation for improvement are included in the RN scope of practice. Focus: Delegation.

Question 18

The charge nurse in a long-term care facility that employs RNs, LPNs/LVNs, and unlicensed assistive personnel (UAP) as staff members is planning the care for an 80-year-old client who has candidiasis in the skinfolds of the abdomen and groin. Which intervention is best to assign to an LPN/LVN?

1. Applying nystatin powder to the area three times daily
2. Cleaning the skinfolds every 8 hours and drying thoroughly
3. Evaluating the need for further antifungal treatment at least weekly
4. Assessing for ongoing risk factors for skin breakdown and infection

Answer 18

Ans: 1
Medication administration is included in LPN/LVN education and scope of practice. Bathing and cleaning clients require the least education and would be better delegated to a UAP. Assessment and evaluation of outcomes of care are more complex skills best performed by RNs. Focus: Assignment; Test Taking Tip: When deciding what nursing actions should be done by staff with various levels of education, remember to consider effective use of resources and use staff to the level of their education. Although LPN/LVN staff members can provide more basic care, it’s best to assign them to interventions that take advantage of their education and scope of practice.

Question 19

After reviewing the medical record for a client who has an oral herpes simplex infection after being treated with chemotherapy, which intervention has the highest priority?

1. Offer reassurance that herpes can be treated with antiviral medication.
2. Administer prescribed analgesics before meals.
3. Offer the client frequent small meals and snacks.
4. Encourage the client to maintain contact with some family members.

Answer 19

INSERT PIC

Ans: 2
The highest priority problems for this client are pain and inadequate nutrition. Administration of analgesics is the most important action because the client’s acute oral pain will need to be controlled to increase the ability to eat and to improve nutrition. The client’s concern about appearance and refusal to see visitors are also concerns but are not as high priority as the need for pain control and improved nutrition. Focus: Prioritization.

Question 20

A client admitted to the emergency department reports new-onset itching of the trunk and groin. The nurse notes multiple reddened wheals on the chest, back, and groin. Which question should the nurse ask next?

1. “Do you have a family history of eczema?”
2. “Have you been using sunscreen regularly?”
3. “How do you usually manage stress?”
4. “Are you taking any new medications?”

Answer 20

Ans: 4
Wheals are frequently associated with allergic reactions, so asking about exposure to new medications is the most appropriate question for this client. The other questions would be useful in assessing the skin health history but do not directly relate to the client’s symptoms. Focus: Prioritization.

Question 21

A client who has extensive blister injuries to the back and both legs caused by exposure to toxic chemicals at work is transferred to the emergency department. Which prescribed intervention will the nurse implement first?

1. Infuse lactated Ringer’s solution at 250 mL/hr.
2. Rinse the back and legs with 4 L of sterile normal saline.
3. Obtain blood for a complete blood count and electrolyte levels.
4. Document the percentage of total body surface area burned.

Answer 21

Ans: 2
With chemical injuries, it is important to remove the chemical from contact with the skin to prevent ongoing damage. The other actions also should be accomplished rapidly; however, rinsing the chemical off is the priority for this client. Focus: Prioritization.

Question 22

The nurse has just received the change-of-shift report in the burn unit. Which client requires the most immediate assessment or intervention?

1. A 22-year-old client admitted 4 days previously with facial burns due to a house fire who has been crying since recent visitors left
2. A 34-year-old client who returned from skin-graft surgery 3 hours ago and is reporting level 8 pain (on a scale of 0 to 10)
3. A 45-year-old client with partial-thickness leg burns who has a temperature of 102.6°F (39.2°C) and a blood pressure of 98/46 mm Hg
4. A 57-year-old client who was admitted with electrical burns 24 hours ago and has a blood potassium level of 5.1 mEq/L (5.1 mmol/L)

Answer 22

Ans: 3
This client’s vital signs indicate that the life-threatening complications of sepsis and septic shock may be developing. The other clients also need rapid assessment or nursing interventions, but their symptoms do not indicate that they need care as urgently as the febrile and hypotensive client. Focus: Prioritization; Test Taking Tip: Remember that when skin integrity is affected due to large burn injuries, clients are at high risk for complications such as sepsis and hypovolemia. You should monitor for changes in vital signs that might indicate these complications are occurring.

Question 23

A client with cellulitis is to receive linezolid 600 mg IV over 2 hours. Based on the medication label, the nurse will set the infusion pump for ____________mL/hr.

Answer 23

Ans: 150
The label indicates 600 mg of medication in 300 mL. To infuse 300 mL in 2 hours, the nurse will need to give 150 mL/hr. Focus: Prioritization.INSERT PIC

Question 24

In which order will the nurse take these actions which are needed for a client seen in the family medicine clinic and diagnosed with impetigo?

1. Obtain specimen for culture.
2. Apply topical antibiotic ointment.
3. Give the client a hand hygiene handout.
4. Clean off the crust from the lesion.
5. Apply a sterile dressing to the wound.

Answer 24

Ans: 4, 1, 2, 5, 3
Culture of the wound will be needed before any antibiotic therapy, but the crust should be removed before wound culture to obtain a specimen that is not contaminated by normal skin bacteria. Application of topical antibiotic will be most effective with the crust removed and should be followed by covering the wound with a sterile dressing. The nurse will provide written teaching materials when the client is not distracted by the culture and dressing activities. Focus: Prioritization.

Question 25

Which personal protective equipment will the nurse need when planning a dressing change for a client with a methicillin-resistant Staphylococcus aureus–infected skin wound? Select all that apply.

1. Gown
2. Gloves
3. Goggles
4. Surgical mask 5. Booties

Answer 25

Ans: 1, 2
Contact precautions include gown and gloves when doing dressing changes for a client with an infected wound. Booties are not needed for contact precautions. Goggles and a surgical mask may be needed if splashes or sprays are anticipated (e.g., with wound irrigation). Focus: Prioritization.

Question 26

The nurse takes the health history of a client who has been admitted to the same-day surgery unit for elective facial dermabrasion. Which information is most important to convey to the plastic surgeon?

1. The client does not routinely use sunscreen.
2. The client has a family history of melanoma.
3. The client has not eaten anything for 8 hours.
4. The client takes 325 mg of aspirin daily.

Answer 26

Ans: 4
Because aspirin affects platelet aggregation, the client is at increased risk for postprocedure bleeding, and the surgeon may need to reschedule the procedure. The other information is also pertinent but will not affect the scheduling of the procedure. Focus: Prioritization.

Question 27

The charge nurse on a medical-surgical unit is working with a newly graduated RN who has been on orientation to the unit for 3 weeks. Which client is best to assign to the new graduate?

1. A 34-year-old client who was just admitted to the unit with periorbital cellulitis
2. A 40-year-old client who needs discharge instructions after having skin grafts to the thigh
3. A 67-year-old client who requires a dressing change after hydrotherapy for a pressure ulcer
4. A 78-year-old client who needs teaching before a punch biopsy of a facial lesion

Answer 27

Ans: 3
A new graduate would be familiar with the procedure for a sterile dressing change, especially after working for 3 weeks on the unit. Clients whose care requires more complex skills such as admission assessments, preprocedure teaching, and discharge teaching should be assigned to more experienced RN staff members. Focus: Assignment.

Question 28

When the nurse is evaluating a client who has been taking prednisone 30 mg/day to treat contact dermatitis, which finding is most important to report to the health care provider?

1. The glucose level is 136 mg/dL (7.6 mmol/L).
2. The client states, “I am eating all the time.”
3. The client reports frequent epigastric pain.
4. The blood pressure is 148/84 mm Hg.

Answer 28

Ans: 3
Epigastric pain may indicate that the client is developing peptic ulcers, which require collaborative interventions such as the use of antacids, histamine2 receptor blockers, or proton pump inhibitors. The elevation in
blood glucose level, increased appetite, and slight elevation in blood pressure may be related to prednisone use but are not clinically significant when steroids are used for limited periods and do not require treatment. Focus: Prioritization

Question 29

The charge nurse is supervising a newly hired RN. Which action by the new RN requires the most immediate action by the charge nurse?

1. Obtaining an anaerobic culture specimen from a superficial burn wound
2. Giving doxycycline with a glass of milk to a client with cellulitis
3. Discussing the use of herpes zoster vaccine with a 25-year-old client
4. Teaching a newly admitted burn client about the use of pressure garments

Answer 29

Ans: 2
Dairy products inhibit the absorption of doxycycline, so this action would decrease the effectiveness of the antibiotic. The other activities are not appropriate but would not cause as much potential harm as the administration of doxycycline with milk. Anaerobic bacteria would not be likely to grow in a superficial wound. The herpes zoster vaccine is recommended for clients who are 60 years or older. Pressure garments may be used after graft wounds heal and during the rehabilitation period after a burn injury, but this should be discussed when the client is ready for rehabilitation, not when the client is admitted. Focus: Prioritization.

Question 30

Which finding by the clinic nurse about a client who has been taking adalimumab to treat psoriasis is most indicative of a need for a change in therapy?

1. Temperature 100.9°F (38.3°C)
2. Patches of scaly skin on chest
3. Erythema on sun-exposed areas of skin
4. Client report of worsening depression

Answer 30

Ans: 1
Biologic immunomodulating agents such as adalimumab (which are frequently used in autoimmune disorders) increase infection risk and should be discontinued in clients with manifestations of infection. Scaly patches, erythema after sun exposure, and depression need further investigation and may require changes in therapy, but the highest concern is risk for worsening infection if the medication is continued. Focus: Prioritization.

Question 31

At the beginning of the shift, an unlicensed assistive personnel (UAP) tells the nurse, “I have several clients today who have wound infections. I will do my best, but if I put on a gown and gloves every time I go into their rooms, I will never get all the care done!” Which response by the nurse is best?

1. “I know you are busy, but please try to comply with the standard infection control measures because these clients have serious infections.”
2. “Let’s look at the client assignments for today and make changes so that you can give the needed care and maintain good infection control.”
3. “If you are unable to follow infection control standards, perhaps you need a review class in correct use of personal protective equipment.”
4. “Tell me what you think are the most important times to use personal protective equipment to prevent infections from spreading.”

Answer 31

Ans: 2 
Seeking the UAP's input into changes is respectful and helps with team dynamics. This response also most directly addresses the UAP's concern about difficulties with time management. Asking the UAP to try to comply suggests that noncompliance with needed infection control actions is an option. The suggestion that the UAP will have to attend a class is disrespectful because it sounds like a threat, and there is no indication that the UAP needs more training on infection control. Asking the UAP to clarify when personal protective equipment is needed may lead to useful discussion about infection control but should be done when more time is available for discussion. Focus: Delegation.