The nurse is preparing a plan of care for a client requiring a dressing change. What is the most important nursing intervention?

What is the most appropriate nursing diagnosis for a client with a reddened sacrum unrelieved by position change?

The client has sustained the initial phase of a burn injury. The nurse anticipates that the primary focus of the client’s care is:

The charge nurse is instructing a new graduate nurse on the procedure of obtaining a wound culture for a client with a suspected infection. The nurse determines that teaching has been effective when the graduate nurse states:

An intubated client with full-thickness, circumferential burns to the chest is experiencing pressure from edema that is inhibiting chest wall expansion. The nurse anticipates that which of the following is the priority intervention for the client?

The nurse is assessing a client with an abdominal incision and suspects there is a potential for delayed wound healing. Which assessment data that would validate this suspicion?

The client has been diagnosed with secondary syphilis. Which is an appropriate assessment for the nurse to enter into the client’s record?

A client is diagnosed with a fungal infection of the scalp. The nurse would document this as:

A client found unconscious at home is brought to the emergency department. Physical examination shows cherry-red mucous membranes, nail beds, and skin. The nurse interprets these findings as indicating which of the following?

A woman walks into the health clinic and frantically tells the nurse she is worried she might have lice. The nurse performs an assessment and determines that the client has lice when she observes which of the following?

The client has experienced a bite from a dog. The nurse documents this in the client’s record as which type of injury?

A nurse is teaching a female client about the use of isotretinoin (Accutane). The nurse determines that teaching was effective when the client states the need to take:

A client complains of small, red, pruritic dots between his fingers and toes. Based on the assessment data, the nurse recognizes that the client most likely has which condition?

A client has a rash consisting of scattered lesions on various parts of the body. Based on the assessment, the nurse recognizes these lesions as being:

A nurse is assessing a client recently admitted to the hospital and observes hair loss in small round circles on the client’s scalp. The nurse documents this assessment finding as:

A client is diagnosed with atopic dermatitis. He is upset and asks how to avoid another outbreak. The nurse determines that the client needs information regarding:

A client has rough papules on the soles of his feet that are sometimes painful when he walks. The nurse suspects that the client has:

A client has recently been diagnosed with tinea corporis. The nurse would document this assessment finding as:

The nurse is caring for a client who has thick, discolored nails that have “ice pick” pits and ridges and splintered hemorrhages and that easily separate from the nail bed. The nurse explains to the client that these findings are associated with which condition?

The home health care nurse is assessing a client. During the assessment, the client tells the nurse that the doctor has recently prescribed nystatin (Mycostatin). The nurse determines that further teaching is not necessary when the client states:

A client is examined and found to have pinpoint, pink-to-purple, nonblanching macular lesions 1 to 3 mm in diameter. The nurse documents this assessment as:

The nurse is assessing a client in the emergency room who was bitten by a brown recluse spider. Documentation of the assessment is correct when which of the following assessments has been recorded in the client’s record?

A client has just been admitted to the hospital after sustaining partialthickness burns to both lower extremities and portions of the trunk. The nurse is aware that the most important I.V. fluid to administer is:

A client arrives at the office of his physician complaining of a rash. The nurse assesses the client and notes several palpable, elevated masses, each about 0.5 cm. The nurse documents these assessment findings using which term?

A client has just arrived at the emergency department after sustaining a major burn injury. During the first 8 hours after the injury, the nurse will assess the client for which of the following?

A 19-year-old client comes to the clinic with dark red lesions on her hands, wrist, and waistline. She has scratched several of the lesions, and they are open and bleeding. The nurse instructs the client to try pressing on the itchy lesions. The nurse explains that pressing on the skin:

The nurse is assessing a 30-year-old client admitted to the emergency department with a deep partial-thickness burn on his arm after a fire in the workplace. The nurse documents the assessment findings as:

The home health nurse assesses four clients. The nurse determines that which client is at highest risk for impaired wound healing after surgery?

A potential exposure to tuberculosis has occurred at a large, rural high school. The school nurse provides instruction to a group of community nurses who have volunteered to assist in the administration of the Mantoux test for the students. The school nurse determines that further instructions are not required when a volunteer nurse makes which statement?

The nurse is providing care for a client admitted to the burn unit. Select the most appropriate statement that identifies the nutritional needs of the client.