Question 1

Which statement made by a client about her neonate indicates the need for further teaching?

Accepted Answer

Answer reason: Newborn bathing education prioritizes thermoregulation and umbilical cord care to reduce hypothermia and infection risk. A tub bath immediately on arriving home can chill a neonate and can unnecessarily wet the umbilical stump; sponge baths are typically recommended until the cord falls off and the site is healed. The other statements reflect appropriate safety practices (back-to-sleep positioning, back-seat car seat placement) and a reasonable strategy to minimize injury during nail trimming. Therefore this statement signals a gap in teaching about safe newborn hygiene timing and method.

Question 2

The client has sustained a burn wound. What is the most important intervention by the nurse to decrease hypertrophied scarring during later stages of healing?

Accepted Answer

Answer reason: Hypertrophic scarring after burns is driven by excessive collagen deposition during remodeling, and sustained external pressure helps flatten scars by reducing tissue edema and local blood flow and by mechanically influencing collagen alignment. Pressure garments/elastic wraps are a standard long-term intervention once the wound is closed or grafts are stable to minimize hypertrophic scar formation. Routine dressing changes support healing and infection prevention but do not specifically prevent hypertrophic scarring in later stages. Sun protection helps prevent hyperpigmentation and photosensitivity of new skin, not the development of hypertrophic scar tissue.

Question 3

A client has been receiving moist saline dressings to an open ulcer of the foot for 10 days. The nurse is assessing the current status of the wound and determines that treatment has been effective when the area appears as which of the following?

Accepted Answer

Answer reason: A dry, crusted scab indicates the wound is drying and sealing, suggesting reduced exudate and advancement toward closure with this dressing regimen. Red, swollen tissue and warm, painful tissue are classic inflammatory or infectious findings that would suggest worsening or complications rather than effective treatment. A deep, wide keloid is an overgrowth of scar tissue seen during later remodeling and would not be an expected short-term sign of effective management of an open foot ulcer.

Question 4

The toddler with eczema is being seen in the clinic. What information should the nurse include when teaching the parent?

Accepted Answer

Answer reason: Teaching parents to recognize and avoid triggers (e.g., harsh soaps/fragrances, wool, heat/sweating, low humidity, some detergents) reduces flare frequency and the itch–scratch cycle. Frequent bathing aimed at “removing flaking skin” can worsen dryness if not paired with appropriate gentle cleansing and immediate emollient use, so it is not the best general teaching point as written. Routine use of topical antibiotics is inappropriate unless there are signs of secondary bacterial infection and it should not be encouraged as an OTC self-treatment. “Silvery scaling” suggests psoriasis rather than eczema and forcibly removing scale can injure skin and worsen symptoms.

Question 5

A 6-year-old child is evaluated after sustaining burns to his left shoulder. After the parents are instructed to use moisturizing cream and protect the burn from sunlight, they question the nurse about the purpose of the treatment. The nurse explains that the treatment will decrease?

Accepted Answer

Answer reason: Healing burn tissue is prone to post-inflammatory pigment changes, and ultraviolet exposure increases melanocyte activity and darkens the area. Moisturizers help maintain an intact, hydrated barrier and reduce irritation and inflammation that can worsen pigment alteration. Sun protection limits UV-driven darkening while the new epithelium matures, making it a key teaching point for burns. While scarring risk is influenced more by burn depth, infection, and wound tension, the specific instruction to protect from sunlight primarily targets pigment darkening.

Question 6

The nurse is observing the UAP providing oral hygiene to the client Which action by the UAP requires follow-up?

Accepted Answer

Answer reason: An unconscious client lacks protective airway reflexes, so positioning during oral care must minimize aspiration risk. Supine positioning promotes pooling of secretions and increases the chance of aspiration of water, toothpaste, or oral debris. The safer approach is side-lying (lateral) or semi-Fowler’s with the head turned to the side, with suction available as needed. The other actions reflect standard oral-care technique and infection control and do not create the same immediate safety hazard.

Question 7

The nurse is caring for the newly admitted male client who is unconscious. The UAP asks if the client should be shaved. What is the nurse’s best response?

Accepted Answer

Answer reason:  Personal hygiene care should respect client autonomy and usual grooming practices whenever possible, especially for non-urgent cosmetic tasks. Because the client is unconscious and newly admitted, the nurse should first determine prior preferences (e.g., from family/caregiver or existing documentation) before directing the UAP to shave. Shaving is not time-critical and can be deferred until preferences are known to avoid unwanted alteration of appearance and potential skin injury. A common distractor is focusing on technique (like using an electric razor), but the priority here is consent/preferences rather than the method.

Question 8

The nurse is preparing to administer otic drops into the adult client’s right ear. Which action should the nurse implement?

Accepted Answer

Answer reason: In adults, straightening the external auditory canal requires pulling the pinna/auricle up and back to allow the medication to flow down the canal toward the tympanic membrane. This positioning improves delivery and reduces the chance that drops will pool in the outer canal. Touching the ear or inserting an applicator into the canal increases contamination and trauma risk and is not necessary for correct administration. Pulling the auricle down and back is the technique used for children under about 3 years old, making it inappropriate for an adult.

Question 9

Which client has the greatest need for perineal care?

Accepted Answer

Answer reason: Indwelling urinary catheters significantly increase risk for catheter-associated urinary tract infection, and meticulous perineal hygiene helps reduce bacterial colonization around the urethral meatus. Needing assistance with ADLs implies limited ability to perform effective self-hygiene, further increasing risk for moisture-associated skin damage and infection. Compared with postpartum lochia or menstruation, the presence of a catheter creates a direct pathway for ascending infection, making hygiene and skin protection most critical. An independent uncircumcised male may need teaching about foreskin hygiene, but he can typically perform care safely himself.

Question 10

A client has a stage II sacral pressure ulcer that is being treated with a transparent film dressing. The nurse is aware that?

Accepted Answer

Answer reason: Transparent film dressings are occlusive/semi-occlusive and are used to support moist wound healing while protecting the area from friction and external contamination. A stage II pressure injury is partial-thickness, and maintaining a moist environment promotes epithelial cell migration and faster re-epithelialization. Allowing the dressing to dry out before removal is not a desired goal for this type of dressing and can increase skin trauma if adhesive is pulled from fragile tissue. Films are not packed into wounds; packing is for deeper cavities/tunneling, whereas films are applied as a flat cover over superficial wounds.

Question 11

A client underwent an enucleation of the right eye for a malignancy. Which intervention will the nurse perform?

Accepted Answer

Answer reason: Gentle cleaning with mild soap and water is an appropriate routine care measure once the prosthesis is in place per provider instructions. Miotics are not used in an eye that has been removed, and pupillary assessment of the removed eye is not possible. Teaching to avoid straining is more relevant to conditions where elevated intraocular pressure threatens an intact globe (e.g., glaucoma or post–intraocular surgery), not an enucleated eye.

Question 12

A parent tells the nurse that the skin in the diaper area of their 6-month-old infant is excoriated and red. What is the most appropriate information for the nurse to tell the parent?

Accepted Answer

Answer reason: Diaper dermatitis is primarily caused by prolonged moisture, friction, and contact with urine/stool, so reducing skin exposure time is the key preventive and treatment step. More frequent diaper changes keep the area cleaner and drier, limiting further maceration and breakdown of already excoriated skin. Talcum powder is avoided due to inhalation/aspiration risk and does not address the core irritant exposure. Vigorous washing increases irritation and disrupts the skin barrier, and restricting fluids is unsafe for an infant and risks dehydration without appropriately treating the rash.

Question 13

The nurse is observing the nursing student caring for the client with an artificial eye. What action by the student nurse would require intervention?

Accepted Answer

Answer reason: Routine removal is generally not required on a fixed weekly schedule; it is typically removed only as needed (e.g., discomfort, excessive secretions) and per provider/ocularist instructions. The other actions reflect safe technique: removing while lying down reduces risk of dropping/breaking it, normal saline is appropriate for rinsing, and gentle drying before reinsertion helps reduce irritation from retained fluid. A rigid “weekly removal” instruction increases handling without clinical need and therefore warrants correction.

Question 14

The client had basal cell carcinoma (BCC) lesions excised the day before at an outpatient clinic. The client telephones the nurse expressing concerns that the wounds are draining watery, pale pink fluid and that the small dressing is leaking. Which action should the nurse recommend?

Accepted Answer

Answer reason: The safest nursing advice is to reinforce care at home by replacing the dressing using clean technique and monitoring for abnormal findings (increasing redness, warmth, swelling, purulent drainage, fever, uncontrolled bleeding). Contacting the surgeon is indicated if drainage becomes bright red/heavy, foul-smelling, or is accompanied by signs of infection or wound dehiscence, which are not described here. Ice and analgesics may help discomfort or swelling but do not address a leaking dressing and are not the priority for this concern.

Question 15

The nurse is caring for the client who had a surgical repair of a right Dupuytren’s contracture. Which intervention should the nurse plan?

Accepted Answer

Answer reason: Planning temporary assistance with activities of daily living supports safety, preserves surgical repair integrity, and reduces strain on the operative hand. Elevation and elastic rewrapping are not appropriate as written because they are nonspecific to the operative hand and could lead to improper compression or positioning if done routinely without assessment. Teaching about footwear is unrelated to this upper-extremity postoperative problem.

Question 16

The nurse is taking the client’s temperature. What should the nurse do to correctly obtain the temperature with a tympanic thermometer?

Accepted Answer

Answer reason: Tympanic thermometry measures infrared heat from the tympanic membrane, so accurate results depend on proper positioning and an airtight fit to prevent ambient air from affecting the reading. A secure seal also helps aim the sensor toward the tympanic membrane rather than the ear canal wall. Routine irrigation is unnecessary and could cause discomfort or alter the measurement environment. Pulling the pinna downward is incorrect for adults (the canal is straightened by pulling up and back), and tympanostomy tubes are not the key step for correct technique compared with achieving a proper seal and alignment.

Question 17

What is the best way for the nurse to assess a client with a dark skin tone?

Accepted Answer

Answer reason: Accurate skin assessment in darker skin tones relies on evaluating areas where pigmentation interferes least with observing color changes. Mucous membranes and lightly pigmented areas (e.g., conjunctiva, oral mucosa, nail beds, palms/soles) make it easier to identify baseline coloration and detect findings like pallor or cyanosis. This approach improves sensitivity for subtle changes that may be missed when relying only on more heavily pigmented skin surfaces. Using only brighter fluorescent light is not the key principle and can still miss clinically important changes if the wrong assessment sites are chosen. Dismissing the need to assess for changes is unsafe because skin findings can signal hypoxia, anemia, infection, or pressure injury across all skin tones.

Question 18

Which client is at the greatest risk for ineffective oral hygiene?

Accepted Answer

Answer reason: Chemotherapy commonly causes mucositis, xerostomia, and oral ulcerations, which make brushing painful and lead to rapid decline in oral intake and self-care. Severe nausea/vomiting further reduces the client’s ability and motivation to perform mouth care and increases exposure of teeth/oral mucosa to gastric acid, worsening irritation and breakdown. This combination creates both high physiologic risk (tissue injury/infection) and practical barriers to effective hygiene. By comparison, knee surgery or mild unilateral weakness typically allows assisted or adaptive oral care without the same degree of mucosal injury risk.

Question 19

The UAP is caring for the client who has been placed in bilateral wrist restraints. Which direction should the nurse give to the UAP?

Accepted Answer

Answer reason:  Clients in restraints are at higher risk for impaired circulation, pressure injury, and unmet basic needs because mobility and access to fluids/toileting are restricted. A UAP can safely carry out comfort measures such as offering fluids and assisting with elimination on a scheduled basis to reduce dehydration and incontinence/skin breakdown. Option D is inappropriate because assessment (skin condition) is a nursing function, not a UAP task. Option A is unsafe because restraints cannot be independently loosened/adjusted without following facility policy and nursing direction, and must still allow adequate circulation.

Question 20

The client has dentures, including both upper and lower plates. Which technique should the nurse use to correctly perform oral hygiene for this client?

Accepted Answer

Answer reason: Proper denture removal uses firm, non-slippery grip and gentle rocking to break the seal without damaging the appliance or injuring oral mucosa. Gauze improves traction on the denture surface and allows controlled movement to loosen it safely. Sterile gloves are not required for routine oral care (clean gloves are sufficient), and the order of removing plates is not the key safety technique. Prying with a foam swab risks trauma and denture breakage, and brushing dentures while they are in the mouth increases aspiration risk and prevents thorough cleaning of the denture and underlying gums.

Question 21

The nurse is giving report to the NA on the care of four clients. The nurse should inform the NA to avoid taking a rectal temperature for which client?

Accepted Answer

Answer reason: Rectal temperatures can cause microabrasions of the rectal mucosa and may provoke bleeding that is difficult to control in a low-platelet client, so this route should be avoided. In immunocompromised oncology patients, rectal manipulation also increases infection risk due to potential bacterial translocation. In contrast, clients with hypothermia may need core temperature monitoring, but a safer noninvasive method should be used when bleeding risk is present.

Question 22

Which client is at the highest risk for periodontal disease?

Accepted Answer

Answer reason: Periodontal disease risk rises with factors that impair immunity and tissue perfusion and that increase oral bacterial burden. Diabetes is strongly associated with gingivitis/periodontitis due to impaired neutrophil function, microvascular changes, and delayed healing, and older age further increases vulnerability. A partial plate can trap plaque and create additional surfaces for biofilm accumulation if meticulous denture/oral care is not maintained. By comparison, the younger clients without diabetes or significant systemic disease have fewer major risk amplifiers for periodontitis, even if flossing habits are suboptimal.

Question 23

The nurse is bathing a comatose client. Which nurse’s note best describes additional nursing activities that can be done during the bed bath?

Accepted Answer

Answer reason: Client bathed; tolerated well; no skin lesions noted. IV flushes well; site is clear. Dressing is clean, dry, and intact. Leg, arm, and neck rangeof-motion exercises done; no contractures or joint swelling noted. Bed bathing a comatose client is also an opportunity to complete focused skin, line, and musculoskeletal assessments and provide preventive care. This note documents tolerance of care plus important concurrent activities during hygiene: skin inspection for breakdown, IV site and dressing assessment, and range-of-motion to reduce immobility complications. It also includes outcome-focused findings (no lesions, site clear, no contractures/swelling), which supports continuity of care and early detection of problems. A more limited note omits key assessments, and documenting participation in an invasive procedure is not an expected or appropriate “during bed bath” activity.

Question 24

The nurse is caring for a 30-year-old female patient with ulcerative colitis. The nurse decides to include ‘risk for altered skin integrity related to frequent and loose bowel movement’. Which of the following is most helpful in preventing perianal skin breakdown?

Accepted Answer

Answer reason: Mild soap and water minimizes friction and chemical irritation while effectively removing stool residue. Thorough drying reduces prolonged moisture contact, which is a major driver of skin breakdown. An antimicrobial scrub is unnecessarily harsh and can strip the skin barrier, and enemas increase stooling and perianal exposure rather than preventing injury.

Question 25

A 75 y/o woman in an assisted living home has been diagnosed with asteatosis eczema on her legs. Which of the following nonpharmacologic therapies is not part of her plan of care?

Accepted Answer

Answer reason: Antibacterial soaps are typically more drying/irritating and can worsen xerosis and pruritus, increasing risk of fissures and secondary infection from scratching. Standard care instead emphasizes brief lukewarm bathing and immediate moisturization (“soak and seal”) to restore barrier hydration. A common trap is assuming “antibacterial” is protective, but routine use is unnecessary without infection and can exacerbate dermatitis.

Question 26

Which measure should be implemented promptly after a client's nasogastric (NG) tube has been removed?

Accepted Answer

Answer reason: NG tubes commonly cause dry mouth, mucosal irritation, and unpleasant taste/odor from gastric secretions, so immediate nursing care focuses on restoring comfort and reducing mucosal breakdown. Oral care also decreases bacterial load and supports swallowing comfort after the tube is removed. Offering fluids is not the first action because oral intake should follow the prescribed diet/aspiration risk assessment rather than being automatic. Cough/deep breathing and bowel-sound assessment are not priority, routine immediate actions specifically tied to NG tube removal.

Question 27

Which of the following statements by a diabetic patient indicates a need for further teaching?

Accepted Answer

Answer reason: ” Diabetes commonly causes peripheral neuropathy and decreased sensation, increasing risk of unrecognized thermal injury. Hot water soaks can lead to burns and skin breakdown, which then predispose to infection and ulceration with impaired wound healing. Safe foot care teaching emphasizes keeping feet clean/dry and using warm (not hot) water with temperature checked by a thermometer or another person if needed. Daily inspection with a mirror, protective closed-toe footwear, and routine podiatry follow-up are appropriate preventive strategies to reduce complications.

Question 28

Which position would be best for a female patient to be in while the nurse provides perineal care?

Accepted Answer

Answer reason: This position places the patient supine with knees flexed and hips externally rotated, which optimizes access for cleansing from front to back and helps the nurse avoid contaminating the urethral area. It also supports stable alignment and is commonly used for female perineal hygiene and catheter-related care. Prone and semi-Fowlers limit access and visualization, while side-lying can be useful in select cases but generally provides less direct access for thorough anterior cleansing.

Question 29

A nurse cares for a client with hypothyroidism. The nurse recommends which intervention to provide comfort for the client?

Accepted Answer

Answer reason: Hypothyroidism reduces metabolic rate and causes decreased sweating and perfusion, commonly leading to dry, coarse skin and pruritus. Applying emollients after bathing helps seal in moisture, decreases itching, and improves skin comfort and integrity. A cool room would worsen the client’s cold intolerance, and hypothyroidism more often causes constipation (so low-fiber diet and antidiarrheals are inappropriate). This intervention is low risk and directly targets a frequent comfort problem in hypothyroidism.

Question 30

While irrigating a wound, how high should the nurse hold the syringe above the site?

Accepted Answer

Answer reason: Holding the syringe a few inches above the wound helps create a controlled, moderate flow that cleans without damaging fragile granulation tissue. A very low height can result in inadequate cleansing and poor mechanical removal of contaminants. A much higher height can increase force unpredictably and increase splash/aerosolization risk, compromising safety and cleanliness of the field.

Question 31

The nurse is preparing to provide oral care for an unconscious patient. How high should the head of the bed be raised?

Accepted Answer

Answer reason: Elevating the head of bed to at least 45° uses gravity to reduce pooling of secretions and oral fluids in the posterior pharynx, lowering the risk of aspiration. This positioning also facilitates oral secretion drainage and improves ventilation compared with lower angles. Higher angles (e.g., 60°) may be used if tolerated, but the key safety threshold commonly taught for procedures with aspiration risk is at least 45°.

Question 32

The health care provider has just removed the cast from a 20-year-old client’s lower leg. During the removal, a small superficial abrasion occurred over the ankle. Which statement by the client indicates the need for additional client teaching?

Accepted Answer

Answer reason: After cast removal, the skin is dry and fragile. Applying lotions immediately—especially near areas of broken skin—can increase the risk of irritation or infection. The skin should be gently cleaned and allowed to recover naturally before using lotions. Option A is correct, as peeling resolves naturally. Option C is appropriate for cleaning a superficial abrasion. Option D is correct because swimming with an open abrasion increases infection risk.

Question 33

While irrigating a wound, when does the nurse know to stop?

Accepted Answer

Answer reason: The most reliable endpoint is the appearance of the effluent, because wound size, depth, and amount of drainage vary widely between patients. Stopping after a fixed time, number of passes, or a set volume risks either inadequate cleansing or unnecessary tissue trauma from over-irrigation. Clear runoff indicates effective removal of loose material while minimizing disruption of viable granulation tissue.

Question 34

How should a patient be positioned for most gynecologic exams?

Accepted Answer

Answer reason: The lithotomy position (supine with hips and knees flexed, feet supported in stirrups) provides the necessary alignment for speculum insertion and bimanual examination. Compared with Fowler’s positions, it offers more consistent exposure of the perineal area and better control of leg support. Trendelenburg is generally reserved for specific procedures and can increase aspiration risk and patient discomfort, making it inappropriate for routine exams.

Question 35

When providing mouth care for an unconscious patient, the most appropriate position for the patient is?

Accepted Answer

Answer reason: Turning the patient to a lateral (side-lying) position allows secretions and rinse water to drain out of the mouth by gravity rather than pooling in the oropharynx. This positioning also facilitates safe suctioning and reduces the chance of fluids entering the trachea. Supine positioning increases aspiration risk, while Fowler’s or semi-Fowler’s may still allow fluid to run posteriorly if protective reflexes are absent.

Question 36

A nurse is assisting a client who has experienced a left-sided cerebral vascular accident (CVA). The client requires assistance with personal hygiene. What is the nurse’s initial intervention?

Accepted Answer

Answer reason: Initial nursing care follows the nursing process, so assessment must occur before implementing interventions or teaching. After a left-sided CVA, the client may have variable motor, sensory, visual, or cognitive-perceptual deficits that determine the safest way to perform hygiene and the degree of assistance required. Establishing baseline function guides choices such as assistive devices, cueing strategies, setup, and supervision to prevent falls and promote independence. For example, encouraging self-care is appropriate, but it should be tailored to the client’s actual capacity to avoid frustration, aspiration/choking risk during oral care, or injury. Placing items on the left side is potentially inappropriate if that side is weak or neglected and should be based on the assessed pattern of deficit.

Question 37

Situation : The nurse is performing health education activities for Jane Segovia, a 30 years old Dentist with Insulin dependent diabetes Mellitus. Q. The nurse is teaching plan of care for Jane with regards to proper foot care. Which of the following should be included in the plan?

Accepted Answer

Answer reason: Moisturizing dry skin helps prevent cracking and fissures that can become portals for infection, but lotion between toes is avoided to reduce moisture and maceration that promotes fungal growth. Soaking in hot water is unsafe because decreased sensation can lead to thermal burns. Mild soap is typically recommended (not avoided), and while high-risk clients may need professional nail care, the absolute “never cut them yourself” is not universally required for all stable patients with good vision and dexterity.

Question 38

The nurse is performing an admission assessment of a patient and discovers what appears to be a pressure injury covered by a large amount of slough. How should this be staged?

Accepted Answer

Answer reason: A large amount of slough prevents determining whether full-thickness loss extends into subcutaneous tissue, muscle, or bone. In this situation the correct staging term is used until enough devitalized tissue is removed to expose the wound bed for reassessment. A common mistake is labeling it Stage III or IV based on suspicion, but staging requires visualization of the deepest viable tissue.

Question 39

Which of the following instructions is inappropriate for promoting skin integrity during radiation therapy?

Accepted Answer

Answer reason: Scented bar soaps can irritate and dry the skin, especially in areas exposed to radiation. Recommended skin care includes gentle cleansing with lukewarm water and mild, non-perfumed soap if approved by the healthcare provider. The other options are appropriate interventions: avoiding unapproved topical products, wearing soft cotton clothing, and protecting the area from sun and temperature extremes all help maintain skin integrity during radiation therapy.

Question 40

Regular oral hygiene is an essential intervention for the client who has had a stroke. Which of the following nursing measures is inappropriate when providing oral hygiene?

Accepted Answer

Answer reason: Post-stroke clients often have impaired swallowing and reduced gag/cough reflexes, increasing aspiration risk during oral care. Supine positioning allows oral secretions and rinse water to pool in the oropharynx and can be aspirated, so the safer position is side-lying or upright with the head turned to the side. Having suction available directly reduces aspiration risk by removing pooled secretions promptly. Using a padded tongue blade and a toothbrush are appropriate techniques when done gently to avoid oral trauma and to maintain oral hygiene.

Question 41

A client has a wound with a moderate amount of drainage and is scheduled for a dressing change. Which dressing, if selected by the student nurse, requires further intervention by the nursing instructor?

Accepted Answer

Answer reason: Transparent film dressings are best for clean, superficial wounds with minimal to no drainage because they have limited absorptive capacity. Using a film on a moderately draining wound can trap moisture and exudate against the skin, increasing leakage and periwound breakdown and raising infection risk. In contrast, foam and alginate dressings are designed to absorb moderate (to heavy, for alginates) exudate, making them more appropriate choices in this scenario.

Question 42

Your patient with chronic renal failure reports pruritus. Which instruction should you include in this patient’s teaching plan?

Accepted Answer

Answer reason: Keeping nails short and clean reduces excoriations, decreases bacterial load under the nails, and lowers risk for skin breakdown and cellulitis. Vigorous rubbing and frequent bathing can worsen xerosis and itching by stripping protective skin oils. Alcohol-based products are drying and typically exacerbate pruritus rather than relieve it.

Question 43

The clinic nurse is reviewing self-care management of acne vulgaris with an adolescent client. Which client statement indicates a need for further instruction?

Accepted Answer

Answer reason: " Acne self-care emphasizes gentle cleansing to reduce irritation and avoid worsening inflammation. Scrubbing and using harsh/antibacterial soaps can overdry and irritate the skin, increasing redness and prompting rebound sebum production, which can exacerbate acne lesions. Appropriate teaching is to wash with a mild cleanser using gentle technique (no vigorous rubbing) and to avoid abrasive products. In contrast, choosing noncomedogenic products and avoiding picking/squeezing are correct behaviors that help prevent pore occlusion, secondary infection, and scarring.

Question 44

A nurse is teaching the parent how to care for a newly circumcised newborn. Which statement by the parent indicates that further teaching is needed?

Accepted Answer

Answer reason: " Post-circumcision care focuses on gentle cleansing and preventing irritation to promote healing and reduce bleeding risk. Alcohol-based products and soap can irritate the tender glans and disrupt healing; routine care is typically warm water cleansing with application of petroleum as instructed. Foul odor and purulent discharge are warning signs of infection that should prompt evaluation. Frequent diaper changes help keep the area clean and dry, which supports normal healing.

Question 45

The nurse has applied the prescribed dressing to the leg of a client with an ischemic arterial leg ulcer. Which method should the nurse use to cover the dressing?

Accepted Answer

Answer reason: In clients with arterial insufficiency, protecting fragile skin and avoiding additional constriction or injury is essential because tissue perfusion is already compromised. Securing the covering without taping directly to the skin reduces risk of skin tears, blistering, and impaired circulation from tight or adherent tape. Taping the end of the wrap to the wrap itself keeps the dressing in place while minimizing trauma during removal and reassessment. Options that involve taping directly to the skin increase the likelihood of skin damage and can worsen local ischemia, especially in older adults or those with compromised integument.

Question 46

The nurse is caring for an 83-year-old bedridden client experiencing fecal incontinence. Which nursing intervention is the highest priority for this client?

Accepted Answer

Answer reason: A barrier cream provides prompt protection by reducing maceration and limiting chemical irritation from stool, making it the most time-sensitive bedside action. Incontinence briefs can trap moisture and increase skin breakdown if used as the primary strategy without meticulous cleansing and barrier protection. Rectal tubes are invasive and carry risks (mucosal injury, leakage, infection) and are not first-line for routine fecal incontinence management; specialist consult is helpful but does not address the immediate need to protect skin now.

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