Test Bank For Medical-Surgical Nursing 10th Edition By Donna
Ignatavicius, M. Linda Workman 9780323612425 Chapter 1-69
Complete Guide .
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
c. Disturbed Body Image
d. Risk for Deficient Fluid Volume - ANSWER: ANS: B
Any wound left to heal by second intention is an open wound and is at risk for infection. Usually,
within 2 days after the surgery, discomfort is minimal and the wound is not draining sufficiently for
the client's fluid balance to be deficient. The client could have a disturbed body image in this
situation, although wounds on the coccyx are not visible to the public. However, the priority in this
situation is to prevent infection.
Which nursing intervention will best assist a client who is bedridden to keep skin intact?
a. Keeping the skin dry
b. Repositioning the client every 2 hours
c. Using a foam mattress pad
d. Using a lift sheet to move the client up in bed - ANSWER: ANS: D
Friction forces are generated when the client is dragged or pulled across bed linen. Using a lift sheet
will prevent friction. Keeping the skin dry will not keep skin intact. Research actually recommends
turning the client every 20 minutes to minimize vasoconstriction from dependency. A foam mattress
will not significantly decrease pressure to an area.
A nurse determines a client as having a Braden scale score of 9. Which is the nurse's best intervention
related to this assessment?
a. Encouraging the client to lay as still as possible in bed
b. Reassessing the client weekly
c. Increasing the client's fluid intake daily
d. Consulting with the health care provider about increased interventions - ANSWER: ANS: D
A score of 11 or less on the Braden scale indicates severe risk for pressure ulcer development in terms
of decreased sensory perception, exposure to moisture, decreased independent activity, decreased
mobility, poor nutrition, and chronic exposure to friction and shear.
Which client is at greatest risk for pressure ulcer development?
a. Client who has pneumonia
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?
Ignatavicius, M. Linda Workman 9780323612425 Chapter 1-69
Complete Guide .
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
c. Disturbed Body Image
d. Risk for Deficient Fluid Volume - ANSWER: ANS: B
Any wound left to heal by second intention is an open wound and is at risk for infection. Usually,
within 2 days after the surgery, discomfort is minimal and the wound is not draining sufficiently for
the client's fluid balance to be deficient. The client could have a disturbed body image in this
situation, although wounds on the coccyx are not visible to the public. However, the priority in this
situation is to prevent infection.
Which nursing intervention will best assist a client who is bedridden to keep skin intact?
a. Keeping the skin dry
b. Repositioning the client every 2 hours
c. Using a foam mattress pad
d. Using a lift sheet to move the client up in bed - ANSWER: ANS: D
Friction forces are generated when the client is dragged or pulled across bed linen. Using a lift sheet
will prevent friction. Keeping the skin dry will not keep skin intact. Research actually recommends
turning the client every 20 minutes to minimize vasoconstriction from dependency. A foam mattress
will not significantly decrease pressure to an area.
A nurse determines a client as having a Braden scale score of 9. Which is the nurse's best intervention
related to this assessment?
a. Encouraging the client to lay as still as possible in bed
b. Reassessing the client weekly
c. Increasing the client's fluid intake daily
d. Consulting with the health care provider about increased interventions - ANSWER: ANS: D
A score of 11 or less on the Braden scale indicates severe risk for pressure ulcer development in terms
of decreased sensory perception, exposure to moisture, decreased independent activity, decreased
mobility, poor nutrition, and chronic exposure to friction and shear.
Which client is at greatest risk for pressure ulcer development?
a. Client who has pneumonia
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?
