Passpoint-Integumentary Question 1 When assessing a client who is incontinent for risk for developing a pressure ulcer, the nurse should note which factor that can most alter tissue tolerance and lea... d to the development of a pressure ulcer? You Selected: exposure to moisture Correct response: exposure to moisture Explanation: Remediation: Question 2 See full question The nurse is assessing a hospitalized older client for the presence of pressure ulcers. The nurse notes that the client has a 1 inch × 1 inch (3 cm x 3 cm) area on the sacrum in which there is skin breakdown as far as the dermis. What should the nurse note on the medical record? You Selected: stage I pressure ulcer Correct response: stage II pressure ulcer Explanation: Remediation: Question 3 See full question Which factor is most important for the nurse to consider when determining the angle at which to insert the needle for a subcutaneous injection? You Selected: length of the needle Correct response: amount of subcutaneous tissue Explanation: Remediation: Question 4 See full question During the first 48 to 72 hours of fluid resuscitation therapy after a major burn injury, the nurse should monitor hourly which information that will be used to determine the IV infusion rate? You Selected: urine output Correct response: urine output Explanation: Remediation: Question 5 See full question A nurse is preparing a discharge teaching plan for a client with atopic dermatitis. Which instruction should the nurse include in her teaching plan? You Selected: Use a topical skin moisturizer daily. Correct response: Use a topical skin moisturizer daily. Explanation: Remediation: Question 6 See full question A client with deep partial-thickness and full-thickness burns on the arms receives autografts. Two days later, the nurse finds the client doing arm exercises. The nurse provides additional client teaching because these exercises may: You Selected: dislodge the autografts. Correct response: dislodge the autografts. Explanation: Remediation: Question 7 See full question A client has partial-thickness burns on both lower extremities and portions of the trunk. Which I.V. fluid does the nurse plan to administer first? You Selected: Lactated Ringer's solution Correct response: Lactated Ringer's solution Explanation: Remediation: Question 8 See full question The nurse is caring for an immune compromised client with a fungal infection of the scalp. What recommendation should the nurse make to prevent future problems? You Selected: Wash hair with a dandruff-preventing shampoo. Correct response: Avoid sharing combs and brushes. Explanation: Remediation: Question 9 See full question A client has suffered a deep partial-thickness burn to the right arm from a high-voltage source of energy that was not turned off while working on it. What is the priority nursing intervention in the acute phase of care? You Selected: A cardiac monitor should be used for at least 24 hours to anticipate the potential for cardiac dysrhythmias. Correct response: A cardiac monitor should be used for at least 24 hours to anticipate the potential for cardiac dysrhythmias. Explanation: Remediation: Question 10 See full question A client in a semiprivate room is diagnosed with pediculosis corpus. A nurse will initiate treatment after moving the client to another room. The client's roommate asks the nurse for information about the client. What should the nurse say? You Selected: "I'm sorry, but I can't share confidential information." Correct response: "I'm sorry, but I can't share confidential information." .......Continued..... [Show More]
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PASSPOINT-MUSCULOSKELETAL|GASTROINTESTINAL|RESPIRATORY|CARDIOVASCULAR|NEONATE|MOOD, ADJUSTMENT AND DEMENTIA DISORDERS|GENITOURINARY|INTEGUMENTARY|PSYCHOTIC DISORDERS|ANTEPARTUM|INTRAPARTUM|POSTPARTUM|...
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