Exam 21: Tissue Integrity

A client with a burn injury is prescribed mechanical debridement of the wounds.Based on this data,which should the nurse include in the client's plan of care? Select all that apply.

An older adult client diagnosed with chronic obstructive pulmonary disease (COPD)is scheduled for a total knee replacement.What should the nurse include in this client's plan of care?

The nurse is planning care for a client with a surgical wound.Which goal is appropriate for this client?

A client has superficial burns on the hand from boiling water.What can the nurse suggest that the client use to help with the healing of these burns?

A client has a laceration that was closed with tissue adhesive.Which is the process by which this wound will heal?

A home care nurse is caring for a client who is recovering from recent surgical debridement that produced large amounts of exudate.The client's surgical wound has staples that are aiding in the wound healing.When documenting this client's care,which terminology best describes this client's care?

A client shows the nurse an area of erythema,swelling,and lesions under a wedding ring.Based on this data,which condition does the nurse suspect?

After a skin graft procedure to the leg,a client is returned to the burn care unit.Based on this data,which action by the nurse is appropriate?

A client has an excoriated skin area with drainage.Which diagnostic test does the nurse anticipate to diagnose the skin lesion?

A nurse working at a burn center is caring for a client with an electrical burn.According to the American Burn Association,how would this burn be classified?

A client is diagnosed with acute allergic contact dermatitis over 25% of the body.Which prescription does the nurse anticipate for the client?

A client with contact dermatitis tells the nurse about scratching the skin raw at night from the itching.Which response by the nurse is appropriate?

A nurse is planning care for a client with a contact dermatitis.When conducting discharge teaching,which statement by the nurse is appropriate?

The nurse is concerned that a client is at a high risk for a burn injury.Which data supports the nurse's concern? Select all that apply.

A client who sustained burns to both lower extremities complains to the nurse about feeling frustrated by not being able to provide self-care.Which nursing diagnosis would be appropriate for the client at this time?

An older adult client complains of having dry skin.Which items would support this client's complaint? Select all that apply.

A nurse is caring for a client with a Stage II pressure ulcer on the coccyx who is at risk for additional pressure ulcers.Which nursing intervention is appropriate while caring for this client?

The nurse is creating a teaching plan for a client with allergic contact dermatitis.Which instructions are appropriate for the nurse to include for this client? Select all that apply.

The nurse is planning care for a client with contact dermatitis.Which interventions should be included in this plan of care? Select all that apply.

The nurse is evaluating care provided to a client with contact dermatitis.Which observation indicates that treatment has been effective?