Tissue Integrity

The child had a cast applied the previous day for a broken tibia. The mother returns the child to the provider to report swelling and significant pain. Upon assessment, the nurse notes pale, cool toes with a capillary refill time of 6 seconds. The child denies feeling the nurse's assessment but screams in pain when the leg is moved. The nurse anticipates which treatment for this patient? 

An adult weighing 70 kg just arrived to the emergency department (ED) with burns on the front of both legs and the genital region. Using the Parkland formula, how much fluid is to be administered to the patient over the next 8 hours?

The patient has Stage I pressure ulcers on her heels bilaterally. The patient's husband asks the nurse if he can massage her feet. Which is the most appropriate response by the nurse?

Which is the inclusive diagnostic term for benign skin lesions caused by the human papillomavirus (HPV) that infect mucous membranes and the stratified epithelium of the skin?

The patient is admitted to the intensive care unit after starting antibiotics and experiencing a severe drug reaction and erythema multiforme syndrome. The patient has severe mucocutaneous bullae over 42% of the body surface area. The nurse anticipates which diagnosis for this patient?

The patient presents to the emergency department (ED) with flu-like symptoms and mucocutaneous erythematous rash and bullae formation over 38% of the body. The nurse asks the patient if which medications had been taken in the last month? Select all that apply.

The nurse plans which intervention for the patient with toxic epidermal necrolysis?

The nurse is administering intravenous fluids to the patient with toxic epidermal necrolysis. Which parameters are most helpful to assess when determining the appropriate fluid rate for the patient?

The patient developed toxic epidermal necrolysis after receiving phenytoin for seizures. The nurse prioritizes nursing interventions to address which life-threatening comorbidities? Select all that apply.

The patient presents to the primary care clinic complaining of painful itching between his toes. Examination reveals scaling skin, areas of maceration between the toes, and some fissure formation. The nurse plans care to provide education about which diagnosis?

Which statement does the nurse include in discharge teaching to the parents of the 9-year-old who underwent tonsillectomy and adenoidectomy?

The child is brought to the emergency department for lacerations and abrasions to the knees, palms, and face after falling at recess. The parent informs the nurse, “He always bleeds so much with any injury." The nurse suspects which condition?

Mechanical ventilation increases the risk for pneumothorax by which mechanism?

Which is indicated by a positive urea breath test?

Which term does the nurse use to document a 1.5 cm, dark red, fluid-filled lesion on the patient's cheek?

Which term does the nurse use to document the pinpoint, non-blanchable rash in the child who has invasive meningococcal disease (IMD) caused by Neisseria meningitidis? 

The patient with vasculitis has a rash of red marks that are greater than 3 mm and do not blanch when pressed. Which term does the nurse use to document this finding? 

The nurse is caring for the patient with a stage 2 pressure injury on the right heel. The wound is pink with minimal serous drainage and attached borders. Periwound skin is clean, dry, and intact. Which intervention is appropriate for this patient?

The patient has undergone a right myringotomy. Which nursing intervention is appropriate?

The nurse is performing an assessment on the patient with long, thin limbs and fingers who presents for a yearly check-up in no acute distress. The patient is extremely thin and has pectus excavatum. For which assessment finding is the nurse most vigilant in this patient?

The patient has a peritoneal dialysis catheter. The nurse notes the dressing is saturated and prepares to change it. Upon removing the dressing, the nurse notes a foul odor and purulent drainage around the site, which is red. Which action does the nurse take next?

The pediatric patient has simple otitis externa (swimmer’s ear) and is afebrile. The nurse prepares educational materials for which treatment?

During assessment of the patient with an ileostomy, the nurse discovers that the opening of the pouch is about 5/8” inch larger than the stoma. This patient is at increased risk for which adverse outcome?

Which is an example of an orthopedic injury due to microtrauma?

Which actions does the nurse take to obtain a sample for culture from the third degree burn wound that appears to be infected? Select all that apply.

Which statement by the patient recently diagnosed with Crohn's disease indicates more teaching is needed? 

The patient with type 2 diabetes mellitus complains of worsening vision. Retinal changes are noted on ophthalmoscopic examination. The nurse prepares the patient for which test for diagnostic confirmation?

The patient with laryngitis requests tips on nonpharmacological symptom management. The nurse makes which suggestion?

The nurse is providing education to the patient recently diagnosed with Raynaud’s phenomenon. Which information does the nurse include in teaching?

Which is the drug of choice for treatment of Raynaud syndrome?

Following a major natural disaster, the charge nurse receives instruction from superiors to pair patients as roommates to increase the number of available rooms. The first patient to be paired is a 42-year-old patient with cellulitis who has a 103°C fever and tachycardia. The charge nurse places her in a room with which patient?

The nurse is a first responder after a gas explosion at an apartment complex. Which patient does the nurse mark to be treated first?

The nurse is supervising the student nurse who is making a call to the provider about a patient who is decompensating. The student states, “Hello, Dr. Smith. This is Carly and I’m taking care of Alex Wright in room 433. He is in the hospital after surgery for a ruptured appendix. Over my shift his temperature has increased by 4 degrees and his heart rate is elevated. His blood pressure is decreased from the previous shift as well. Could you please come examine him?” Which additional comments are the priority for the nurse to add? Select all that apply.

The nurse notes the patient’s nails appear to curl upwards like spoons. Which statement by the nurse is most appropriate?

The registered nurse on the medical-surgical floor is delegating tasks to an unlicensed assistive personnel, certified medication assistant, and a licensed practical/vocational nurse. Which task does the nurse delegate to the LPN/LVN?

A baby is born precipitously to a mother who did not have prenatal care. The neonate requires only the initial steps of resuscitation but is found to have a bilateral cleft lip and palate. Review the patient’s assessment here: Position at rest: Complete flexion Square window: 0° Arm recoil: 75° Popliteal angle: 80° Scarf sign: Elbow does not cross midline Heel to ear: Foot does not reach the umbilicus Skin: No veins visible, cracking of skin at joints, dry Lanugo: Mostly bald skin Plantar surface: Creases over entire sole Breast: 4 mm bud with raised areola Ear: Formed pinna with instant recoil Genitals: Descended testes bilaterally, rugae over entire scrotum For which referrals does the nurse advocate for the baby prior to discharge? Select all that apply.

The patient is scheduled to undergo a Wood’s light examination. Which instruction does the nurse include in preprocedure teaching?

Which wound most likely requires healing by second intention?

The nurse receives report and learns the patient has a wound that is healing by third intention. Which intervention is most important to include in the patient’s care plan?

The patient receiving which medication is most likely to also require a prescription for miconazole?

The 60-year-old patient who was recently laid off from his factory job of 38 years presents to the emergency department complaining of severe superficial pain over the flank. Which assessment will be most important for diagnosis?

The 74-year-old otherwise healthy patient presents to the clinic complaining of severe pain and burning of the skin over the right flank. Upon assessment, the nurse notes two lines of vesicles that curve laterally away from the spine on the right side. The nurse provides which instruction to the patient regarding treatment?

The patient with shingles presents to the clinic for reassessment following treatment. The nurse asks the patient to perform which action to assess for complications of the condition?

The nurse monitors the patient with erysipelas for which symptoms that may indicate complications related to the condition? Select all that apply.

The patient presents to the urgent care clinic complaining of a blister rash on the arm that burns and itches. The nurse notes a large vesicle on the forearm with streaks of smaller vesicles surrounding it. Which question will be most helpful to diagnose this condition?

The nurse is preparing educational material about brown recluse spider bites. Which information is most important to include?

The 12-year-old child is brought to the emergency room after being bitten by a family friend’s tarantula. The child is healthy and has received all scheduled vaccinations. Which medication must be given as soon as possible?

The patient in Arizona calls the nurse line to report being stung by a scorpion. Which follow-up question by the nurse is most important?

The nurse is supervising the care of a patient with second-degree frostbite. Which action by the student nurse prompts the nurse to intervene with further instruction?

The patient presents to the dermatology clinic for a skin cancer check and a small red papule is found on the right chest. It is noted to have a crater in the middle and have pearly borders. How does the nurse interpret this finding?