Tissue Integrity

The 10-year-old patient presents to the emergency room following a fever as high as 105°F for 5 days. The patient’s mother reports the child has had red, watery eyes, poor appetite, and has felt ill during this time. The child was brought to the emergency room upon the appearance of a red rash that started on the child’s face and spread to the neck and chest. Which question will be most helpful in order to determine the cause of this patient’s symptoms?

The 4-year-old child is admitted with measles. Which medication does the nurse prepare to administer initially?

Which tasks can be delegated to an unlicensed assistive personnel (UAP)? Select all that apply.

The nurse is planning care for the patient with severe liver disease who has substantial ascites and peripheral edema. Which interventions are included in the care plan? 

The patient is brought to the emergency department after a motorcycle accident which resulted in head trauma. The nurse observes a hematoma and bruising around the mastoid bone. Which term does the nurse use to document the finding?

Which statement does the nurse include in preprocedure teaching for the patient who will undergo abdominal paracentesis?

The patient is in the post-anesthesia care unit (PACU) following abdominal surgery. Which finding would prompt the nurse to delay discharge from the PACU to a hospital bed?

The nurse applies a transparent dressing to which type of wound?

The nurse assists with the administration of autolytic debridement for an extremity burn. Which treatment was applied?

The healthcare team is answering questions for a 24-year-old black woman scheduled for a thyroidectomy. She states her mother had the same procedure and has a huge scar that is bigger than the original incision. The nurse understands the mother experienced which type of wound derangement?

The 1.9 kg neonate is born precipitously via vaginal delivery to a 32-year-old mother who received no prenatal care or infectious disease serology testing before delivery. The mother has a history of intravenous drug use. Which intervention does the nurse perform first?

The child suffered a radial fracture that has just been immobilized with a plaster cast. Which action by the nurse is appropriate? 

The patient with a lung mass that was discovered on imaging is scheduled for a flexible bronchoscopy. Which nursing action is appropriate to prepare the patient for the procedure?

The nurse receives shift report on four patients. Which patient does the nurse see first?

The nurse assesses the cuff pressure of the patient's tracheostomy. Which cuff pressure prompts the nurse to document the finding and proceed with the assessment?

The nurse planning care for the neonate with myelomeningocele plans interventions to ensure the child does not develop an allergy to which substance?

The nurse is supervising the student nurse preparing for the return of a neonate from surgery to repair a myelomeningocele. Which item, if brought into the room by the student nurse, does the nurse remove immediately?

The nurse is assisting the provider in lancing the abscess of a patient whose medical history is notable for anaphylaxis after ingestion of oysters. The nurse enters the room as the provider begins swabbing the affected skin with povidone-iodine solution. Which response by the nurse is appropriate?

The nurse is preparing the patient for a magnetic resonance imaging (MRI) scan with intravenous contrast. Which question is most important for the nurse to ask the patient?

The patient is receiving alefacept. Which finding indicates the patient is having the desired response to therapy?

The nurse advocates for the use of secukinumab in which patient?

The patient has experienced an extravasation of norepinephrine in the right forearm. It is cool to the touch, firm, and pale. Distal to peripheral pulses are not well felt and the fingertips are dusky. Which order does the nurse clarify with the provider?

The nurse assesses the peripheral IV site of the patient who is receiving norepinephrine, which was started for profound, life-threatening hypotension and finds the hand to be firm to the touch, cool, and pale. Which action does the nurse take?

Which symptom can occur following vertical transmission of Neisseria gonorrhoeae?

The female patient tells the nurse, “I think the man I had unprotected sex with last night might have herpes. I’m so afraid I’m going to get it, too.” Which response by the nurse is most appropriate?

Which mother is at highest risk for passing herpes simplex virus (HSV) to her fetus/neonate?

The patient presents to the clinic complaining of a painful sore on his penis. Upon assessment, the nurse notes an ulceration with a yellow slough wound base that is soft with an irregular border. The inguinal lymph node on the ipsilateral side of the wound is enlarged and firm. The nurse suspects which organism is the cause of the wound?

The 32-weeks-pregnant woman who presents with genital lesions is diagnosed with herpes simplex virus-2. The nurse prepares a patient information handout for which medication for this patient?

Which patient on the surgical floor is at the greatest risk for abdominal wound dehiscence?

The patient presents to the emergency department (ED) after being bitten by a friend’s dog with two puncture marks and an abrasion. Prior to dressing the wound, the nurse uses which substance to clean the wound?

The elderly patient experienced a large skin tear to the right forearm. Which action by the provider prompts the nurse to intervene?

The nurse requests analgesia for the 76-year-old patient who must undergo cleansing and dressing change for a healing stage 3 pressure ulcer on the coccyx. In response, the provider ordered topical EMLA cream to be applied to the wound 30 minutes before the procedure. Which action by the nurse is appropriate?

The patient returns from cholecystectomy surgery with a wound closed with sutures. There is no drainage from the wound. Which dressing does the nurse apply?

Which wound heals by secondary intention?

Which cell is responsible for cleaning wounds of microorganisms?

Which interventions increase the risk for impaired skin integrity in the patient with congestive heart failure who requires total care? Select all that apply.

Which patient is at highest risk for skin breakdown?

The nurse changes the dressing of the patient with a sacral pressure injury. Upon removal of the dressing, the nurse notes yellow drainage on the dressing with a fruity odor. Place the nurse’s actions in the correct order from first to last.

The nurse identifies which patient at highest risk for delayed wound healing?

The nurse advocates for a guaiac test to be performed on the patient with which stool?

To which team member does the registered nurse delegate a fecal occult blood test for the patient who requires assistance to ambulate to the restroom?

The nurse is supervising a student nurse in caring for a postoperative patient at high risk for surgical wound evisceration. The nurse prepares the student to perform which interventions if the wound eviscerates? Select all that apply.

A man is admitted to the hospital for treatment of burns caused by a brush fire. He was attempting to control the flames and his clothes caught fire. He has burns of various depths on the front and back of both arms, his back, and the back of his head. What is the estimated total body surface area burned?

The patient calls the nurse to the room to report pain at the site of an IV. The nurse notes warmth, redness, and purulent drainage. Which action does the nurse take first?

The patient being treated for a skin wound and cellulitis is in a semi-private room with another patient; the hospital is near capacity. The culture of the wound has grown methicillin-resistant staphylococcus aureus. Which action is most appropriate? 

The patient underwent surgery for creation of a colostomy 2 days ago. Upon assessment, which stoma color prompts the nurse to document the finding and continue with the assessment?

The patient receiving hospice care reports constant, severe dry mouth. Which interventions does the nurse include in the patient's care plan? Select all that apply.

The American Cancer Society recommends the patient's initial cervical cancer screening occurs at which time?

The patient’s wound is producing copious amounts of exudate and the gauze dressing is saturated within two hours of placement. Which intervention does the nurse perform?

The patient receiving sliding scale insulin requests the subcutaneous insulin to be injected into the abdomen. Immediately prior to administration, the nurse notes the site is stringy, slightly indurated, and has several fat masses. Which action by the nurse is appropriate?