CHAPTER 15
Ingumny Poblms
Qusions
1. he nurse ssgns  dressng cnge to te LPN/LVN
on  stge III pressure njury tt s drnng rge
ounts o puruent serosngunous lud. Wc
type o dressng soud te nurse nstruct te LPN/
LVN to utze?
1. A ydropobc dressng
2. Wet to dp sne ostened guze
3. A ydropc dressng
4. A trnsprent dressng
2. Wc ctons w te nurse use wen tretng  p-
tent wt  venous ucer on te rgt ower eg? Select
all tat apply.
1. Poston te rgt eg ower tn te ert.
2. Use copresson wrps consstenty.
3. Adnster ngescs beore wound cre.
4. Mntn  dry wound envronent.
5. Encourge rgt nke lexon exercses.
6. Cen wound wt  nonrrttng souton.
3. Ater te nurse s perored  skn ssessent on
 recenty dtted 19-yer-od ptent, wc nd-
ng s te gest prorty to report to te et cre
provder?
1. Moe 2  n deter on te cest
2. Tentng o te skn on te orers
3. Ptces o vtgo round bot eyes
4. Scttered brown cues on te ce
4. he oe et nurse s crng or  ptent wt 
ung necton o te toens wo s  new pre-
scrpton or or trconzoe. Wc ptent nor-
ton s most portnt to dscuss wt te et
cre provder (HCP) beore dnstrton o te
trconzoe?
1. he ptent’s toens re tck nd yeow.
2. he ptent s ebrrssed by te necton.
3. he ptent s so tkng svsttn dy.
4. he ptent s ergc to odne nd ses.
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5. he et cre provder (HCP) prescrbes peretrn
ppcton or  y ebers o  ptent wo
s scbes. Wc ptent norton w be most
portnt or te nurse to dscuss wt te HCP be-
ore tecng te ptent bout te edcton?
1. he ptent s  newborn nnt.
2. Burrows re noted on te wrsts.
3. he ptent nd y ve n  oeess seter.
4. Fy ebers re syptotc.
6. he nurse s crng or  ptent wo s just d 
squous ce crcno reoved ro te ce.
Wc cton cn be ssgned to n experenced
LPN/LVN?
1. Tecng te ptent bout rsk ctors or squ-
ous ce crcno
2. Sowng te ptent ow to cre or te surgc
ste t oe
3. Montorng te surgc ste or sweng, beedng,
or pn
4. Dscussng te resons or vodng sprn use or
1 week ter surgery
7. he crge nurse n  ong-ter cre (LTC) cty
tt epoys RNs, LPNs/LVNs, nd ssstve person-
ne (AP) s pnnng cre or  resdent wt  stge
III scr pressure njury. Wc nursng nterventon
s best to ssgn to n LPN/LVN?
1. Coosng te type o dressng to be used on te
njury
2. Usng te Brden sce to ssess or pressure njury
rsk ctors
3. Assstng te ptent n cngng poston t re-
quent ntervs
4. Cenng nd cngng te dressng on te njury
every ornng
149
 150 CHaPter 15 Integumentary Problems
8. he nurse s just receved  cnge-o-st report or
te burn unt. Wc ptent soud be ssessed irst?
1. Ptent wt deep prt-tckness burns on bot
egs wo reports severe nd contnuous eg pn
2. Ptent wo s just rrved ro te eergency de-
prtent wt c burns sustned n  ouse re
3. Ptent wo s just been trnserred ro te
postnestes cre unt ter vng skn grts
pped to te nteror cest
4. Ptent dtted 3 weeks go wt u-tckness
eg nd buttock burns wo s been wtng or 3
ours to receve dscrge tecng
Common Hlh Scnios
9. he nurse s perorng  stere dressng cnge or 
ptent wt nected deep prt-tckness burns o
te cest nd bdoen. Lst te steps n te order n
PA RT 2
wc ec soud be ccopsed.
1. Appy sver sudzne ontent.
2. Obtn specens or erobc nd nerobc wound
cutures.
3. Adnster orpne sute 10 g IV.
4. Debrde te wound o escr usng guze sponges.
5. Cover te wound wt  stere guze dressng.
_____, _____, _____, _____, _____
10. Wc ptent s best or te nurse nger on te
burn unt to ssgn to n RN wo s loted ro te
oncoogy unt?
1. A 23-yer-od ptent wo s just been dtted
wt burns over 30% o te body ter  wreouse
re
2. A 36-yer-od ptent wo requres dscrge
tecng bout nutrton nd wound cre ter v-
ng skn grts
3. A 45-yer-od ptent wt nected prt-
tckness bck nd cest burns wo s  dressng
cnge scedued
4. A 57-yer-od ptent wt u-tckness burns
on bot rs wo needs ssstnce n postonng
nd spnts
11. Ater te nurse perors  skn ssessent on 
70-yer-od new resdent n  ong-ter cre cty,
wc ndng s o most concern?
1. Nuerous stre re noted cross te bdoen nd
buttocks.
2. A te toens re tckened nd yeow.
3. Sver scng s present on te ebows nd knees.
4. An rregur border s seen on  bck oe on te
scp.
12. Wc ssessent ndng cs or te most ed-
te cton by te nurse?
1. Bus coor round te ps nd erobes
2. Yeow coor o te skn nd scer
3. Bter eryte o te ce nd neck
4. Drk brown spottng on te cest nd bck
Answer Key or ts cpter begns on p. 154
13. he nurse obtns ts norton bout  60-yer-od
ptent wo s  snges necton. Wc ndng s
o most concern?
1. he ptent s d syptos or bout 2 dys.
2. he ptent s severe burnng-type dscoort.
3. he ptent s not d te erpes zoster
vccnton.
4. he ptent’s spouse s currenty recevng cncer
ceoterpy.
14. Wc o tese ctons w te nurse tke irst or 
ptent wo s rrved n te eergency deprtent
wt sudden-onset urtcr nd ntense tcng?
1. Ask te ptent bout ny new edctons.
2. Adnster te prescrbed cetrzne.
3. Appy topc cortcosterod cre.
4. Auscutte te ptent’s bret sounds.
15. A 22-yer-od won wo s been tkng sotret-
non to tret severe cystc cne kes  tese stte-
ents we beng seen or  oow-up exnton.
Wc stteent s o most concern?
1. “My usbnd nd I re tnkng o strtng  y
soon.”
2. “I don’t tnk tere s been uc proveent n
y skn.”
3. “Soetes I get nuseted ter tkng te
edcton.”
4. “I ve been experencng  ot o usce ces nd
pns.”
16. A ptent s scedued or ptc testng to deter-
ne erges to sever substnces. Wc cton
ssocted wt ts test soud te nurse deegte
to ssstve personne (AP) workng n te ergy
cnc?
1. Expnng te purpose o te testng to te ptent
2. Exnng te ptc re or evdence o  recton
3. Scedung  oow-up ppontent or te p-
tent n 2 dys
4. Montorng te ptent or npyctc rectons
to te testng
17. he nurse s pnnng ospt dscrge tecng or
our ptents. For wc ptent s t most portnt
to nstruct bout te need to use sunscreen?
1. A 32-yer-od ptent wt pneuon wo s 
new prescrpton or doxycycne
2. A r-sknned 55-yer-od ptent wt psorss
wo works outsde or 8 ours dy
3. A drk-sknned 62-yer-od ptent wo s d
keods njected wt ydrocortsone
4. A 78-yer-od ptent wt  red, prurtc rs
cused by n ergc recton to pencn
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 CHaPter 15 Integumentary Problems 151

18. he oe et nurse s crng or  72-yer-od
ptent wo s  stge II pressure njury, wt rsk
ctors o poor nutrton, bdder ncontnence, nd
obty. Wc nursng cton soud be deegt-
ed to te ssstve personne (AP)?
1. Teng te ptent nd y to ppy te skn
brrer cre n  soot, even yer
2. Copetng  det ssessent nd suggestng
cnges n det to prove te ptent’s nutrton
3. Rendng te y to ep te ptent to te
coode every 2 ours durng te dy
4. Evutng te ptent or proveent n docu-
21. A ptent dtted to te eergency deprtent reports
new-onset tcng o te trunk nd gron. he nurse
notes utpe reddened wes on te cest, bck, nd
gron. Wc queston soud te nurse sk next?
1. “Do you ve  y story o ecze?”
2. “Hve you been usng sunscreen regury?”
3. “How do you usuy nge stress?”
4. “Are you tkng ny new edctons?”
22. A ptent wo s extensve bster njures to te bck
nd bot egs cused by exposure to toxc cecs
t work s trnserred to te eergency deprtent.

Common Hlh Scnios

ented res o skn brekdown or dge Wc prescrbed nterventon w te nurse pe-
ent irst?
19. he crge nurse n  ong-ter cre cty tt 1. Inuse ctted Rnger’s souton t 250 L/r.
epoys RNs, LPNs/LVNs, nd ssstve person- 2. Rnse te bck nd egs wt 4 L o stere nor

PA RT 2
ne (AP) s stf ebers s pnnng te cre or n sne.
80-yer-od ptent wo s cnddss n te skn- 3. Obtn bood or  copete bood count nd eec-
ods o te bdoen nd gron. Wc nterventon troyte eves.
s best to ssgn to n LPN/LVN? 4. Docuent te percentge o tot body surce
1. Appyng nysttn powder to te re tree tes re burned.
dy
2. Cenng te sknods every 8 ours nd dryng 23. he nurse s just receved te cnge-o-st report
torougy n te burn unt. Wc ptent requres te most -
3. Evutng te need or urter ntung tret- edte ssessent or nterventon?
ent t est weeky 1. A 22-yer-od ptent dtted 4 dys prevousy
4. Assessng or ongong rsk ctors or skn brek- wt c burns due to  ouse re wo s been
down nd necton cryng snce recent vstors et
2. A 34-yer-od ptent wo returned ro skn-
20. Ater revewng te edc record or  ptent wo grt surgery 3 ours go nd s reportng eve 8
s n or erpes spex necton ter beng tret- pn (on  sce o 0 to 10)
ed wt ceoterpy, wc nterventon s te 3. A 45-yer-od ptent wt prt-tckness eg
gest prorty? burns wo s  teperture o 102.6°F (39.2°C)
nd  bood pressure o 98/46  Hg
Physical Nutritional Social and Emotional
4. A 57-yer-od ptent wo ws dtted wt eec-
Assessment Assessment Assessment
trc burns 24 ours go nd s  bood pots-
• Vesicular • Takingonly • States,“Ifeel su eve o 5.1 Eq/L (5.1 o/L)
esons  ew btes o ke  onster
trougout ec e wt tese 24. A ptent wt ceuts s to receve nezod 600 g IV
out nd erpes sores over 2 ours. Bsed on te edcton be, te nurse
ps  over y w set te nuson pup or ____________L/r.
out!”
• Reportslevel • 2-lb(1-kg) • Refusestosee
9 or pn wegt oss vstors
(on  sce o n pst 3
0 to 10) dys
1. Ofer ressurnce tt erpes cn be treted wt
ntvr edcton.
2. Adnster prescrbed ngescs beore es.
3. Ofer te ptent requent s es nd sncks.
4. Encourge te ptent to ntn contct wt
soe y ebers.

Copyrgt © 2022, Esever Inc. A rgts reserved. Answer Key or ts cpter begns on p. 154
 152 CHaPter 15 Integumentary Problems
25. In wc order w te nurse tke tese ctons tt
re needed or  ptent seen n te y edcne
cnc nd dgnosed wt petgo?
1. Obtn specen or cuture.
2. Appy topc ntbotc ontent.
3. Gve te ptent  nd ygene ndout.
4. Cen of te crust ro te eson.
5. Appy  stere dressng to te wound.
_____, _____, _____, _____, _____
26. Wc person protectve equpent w te nurse
need wen pnnng  dressng cnge or  ptent
Common Hlh Scnios
wt  etcn-resstnt Stapyococcus aureus–n-
ected skn wound? Select all tat apply.
1. Gown
2. Goves
PA RT 2
3. Gogges
4. Surgc sk
5. Bootes
6. Stere goves
27. he nurse tkes te et story o  ptent wo s
been dtted to te se-dy surgery unt or eec-
tve c derbrson. Wc norton s most
portnt to convey to te pstc surgeon?
1. he ptent does not routney use sunscreen.
2. he ptent s  y story o eno.
3. he ptent s not eten nytng or 8 ours.
4. he ptent tkes 325 g o sprn dy.
28. he crge nurse on  edc-surgc unt s work-
ng wt  newy grduted RN wo s been on or-
entton to te unt or 3 weeks. Wc ptent s best
to ssgn to te new grdute?
1. A 34-yer-od ptent wo ws just dtted to te
unt wt perorbt ceuts
2. A 40-yer-od ptent wo needs dscrge n-
structons ter vng skn grts to te tg
3. A 67-yer-od ptent wo requres  dressng
cnge ter ydroterpy or  pressure njury
4. A 78-yer-od ptent wo needs tecng beore 
punc bopsy o  c eson
Answer Key or ts cpter begns on p. 154
29. Wen te nurse s evutng  ptent wo s been
tkng prednsone 30 g/dy to tret contct der-
tts, wc ndng s most portnt to report to te
et cre provder?
1. he gucose eve s 136 g/dL (7.6 o/L).
2. he ptent sttes, “I  etng  te te.”
3. he ptent reports requent epgstrc pn.
4. he bood pressure s 148/84  Hg.
30. he crge nurse s supervsng  newy red RN.
Wc cton by te new RN requres te most -
edte cton by te crge nurse?
1. Obtnng n nerobc cuture specen ro 
superc burn wound
2. Gvng doxycycne wt  gss o k to  ptent
wt ceuts
3. Dscussng te use o erpes zoster vccne wt 
25-yer-od ptent
4. Tecng  newy dtted burn ptent bout te
use o pressure grents
31. Wc ndng bout  ptent wo s been tkng
dub to tret psorss s most ndctve o 
need or  cnge n terpy?
1. Teperture 100.9°F (38.3°C)
2. Ptces o scy skn on cest
3. Eryte on sun-exposed res o skn
4. Ptent report o worsenng depresson
32. At te begnnng o te st, n ssstve personne
(AP) tes te nurse, “I ve sever ptents tody wo
ve wound nectons. I w do y best, but  I put
on  gown nd goves every te I go nto ter roos,
I w never get  te cre done!” Wc response by
te nurse s best?
1. “I know you re busy, but pese try to copy wt
te stndrd necton contro esures becuse
tese ptents ve serous nectons.”
2. “Let’s ook t te ptent ssgnents or tody nd
ke cnges so tt you cn gve te needed cre
nd ntn good necton contro.”
3. “I you re unbe to oow necton contro stn-
drds, perps you need  revew css n correct
use o person protectve equpent.”
4. “Te e wt you tnk re te ost portnt
tes to use person protectve equpent to pre-
vent nectons ro spredng.”
Copyrgt © 2022, Esever Inc. A rgts reserved.
 CHaPter 15 Integumentary Problems 153

33. Coze _______________________________________________________________________________________

Scenaro: A 50-yer-od ptent wt no known erges s sustned 30% Instructons: Copete te sen-
prt nd u tckness burns. he ptent’s bood pressure s dropped sgn- tences beow by coosng te ost
cnty snce dsson 18 ours go. he sgncnt decrese n bood pressure probbe opton or te ssng
ter jor burns s due to 1 . Hs rter bood gses ndcte  etboc norton tt corresponds wt
cdoss. Metboc cdoss n burn vcts nd s cused by 2 . Frst ne te se nubered st o optons
tretent o etboc cdoss ncudes dnstrton o 3 . 4 w be provded.
dnstered to prevent necton wt Costrdum tetan. To prevent yper-
tropc scrs nd contrctures, copresson dressngs or grents re pped.
he ptent ust wer te copresson grents or t est 23 ours  dy or
5 n order to be efectve.

Common Hlh Scnios

Opton 1 Opton 2 Opton 3 Opton 4 Opton 5
Ptent controed Hg bcrbonte Sodu Bcrbonte Vncoycn 6 onts to  yer
nges wt eves

PA RT 2
Morpne
Insucent lud Hypoventton Intrvenous luds Ppercn-tzobct 3 onts to 6 onts
repceent
Septce Decresed tssue Hg low oxygen Tetnus toxod 1 to 2 yers
peruson
Cpry ek Hypox Antbotcs Apotercn B 3 to 4 yers
syndroe

Copyrgt © 2022, Esever Inc. A rgts reserved. Answer Key or ts cpter begns on p. 154