A nurse is assisting with the care of a client with the history below:

Exhibits

A nurse is caring for the client. Which of the following actions should the nurse take? Select (2) answers that apply.

Wear a protective gown while caring for the client.

Place the client in a private room.

Wear an N-95 respirator while caring for the client.

Place the client in a negative pressure room.

Place a mask on the client when they leave their room.

Answer and Explanation

Correct Answer : A,B

A. Wearing a protective gown is necessary when caring for a client with C. difficile to prevent the spread of spores and protect the nurse from contact with contaminated surfaces.
B. Placing the client in a private room helps to isolate the infection and prevent transmission to other patients, which is essential in managing C. difficile infections.
C. An N-95 respirator is not required for C. difficile as the primary mode of transmission is via the fecal-oral route, not through airborne particles.
D. A negative pressure room is used for airborne infections like tuberculosis, not for C. difficile. C. difficile requires contact precautions rather than airborne precautions.
E. A mask is not necessary for the client with C. difficile when leaving the room; instead, hand hygiene and proper gowning are essential for preventing the spread of the infection.

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Correct Answer is C

Explanation

A. Document the client's history of skin allergies: While important for the client's overall care, documenting the history of skin allergies is not the priority when assessing a new skin lesion.
B. Photograph the lesion for the client's medical record: Documenting the appearance of the lesion is important for the client's medical record, but it is not the priority when initially assessing the lesion.
C. Identify when the client first noticed the lesion: The priority is to gather information about the onset and characteristics of the lesion to determine its potential severity and urgency of intervention.
D. Instruct the client on the use of daily sunscreen products: While sun protection is important for skin health, it is not the priority when assessing a new skin lesion.

A. Macule B. Vesicle C. Papule D. Wheal

Correct Answer is B

Explanation

A. Macule: A macule is a flat, discolored area of skin that is smaller than 1 centimeter in diameter and does not contain fluid.
B. Vesicle: A vesicle is a raised, fluid-filled lesion smaller than 1 centimeter in diameter.
Examples include blisters caused by conditions such as herpes simplex virus or contact dermatitis.
C. Papule: A papule is a raised, solid lesion smaller than 1 centimeter in diameter that does not contain fluid. Examples include pimples or insect bites.
D. Wheal: A wheal is a raised, red area of skin that is often accompanied by itching. It is typically caused by an allergic reaction and may have irregular borders.

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A nurse is assisting with the care of a client with the history below: Exhibits A nurse is caring for the client. Which of the following actions should the nurse take? Select (2) answers that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a client who reports finding a new skin lesion. Which of the following actions is the nurse's priority?

Correct Answer is C

Explanation

Which term should the nurse use to document a raised, fluid-filled lesion smaller than 1 centimeter?

Correct Answer is B

Explanation

Which of the following assessments should be performed to monitor for impaired tissue integrity?

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A nurse is assisting with the care of a client with the history below:

Exhibits

A nurse is caring for the client. Which of the following actions should the nurse take? Select (2) answers that apply.