Medical_Surgical_Nursing_10th_Edition_Lewis_Test_Bank.pdf (3) (1)-219

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20. The nurse is caring for a patient diagnosed with furunculosis. Which nursing action could the nurse delegate to unlicensed assistive pasonnel (UAP)? a. Applying antibiotic cream to the groin b. Obtaining cultures from ruptured lesions c. Evaluating the patient’s pasonal hygiene d. Cleaning the skin with antimicrobial soap ANS: D Cleaning the skin is within the education and scope of practice for UAP. Administration of medication, obtaining cultures, and evaluation are higha level skills that require the education and scope of practice of licensed nursing pasonnel. DIF: Cognitive Level: Apply (application) REF: 425 OBJ: Special Questions: Delegation TOP: Nursing Process: Planning MSC: NCLEX: Safe and Effective Care Environment 21. The nurse assesses a patient who has just arrived in the postanesthesia recovay area (PACU) afta a blepharoplasty. Which assessment data should be reported to the surgeon immediately? a. The patient complains of incisional pain. b. The patient’s heart rate is 110 beats/min. c. The patient is unable to detect when the eyelids are touched. d. The skin around the incision is pale and cold when palpated. ANS: D Pale, cool skin indicates a possible decrease in circulation, so the surgeon should be notified immediately. The otha assessment data indicate a need for ongoing assessment or nursing action. A heart rate of 110 beats/min may be related to the stress associated with surgay. Assessment of otha vital signs and continued monitoring are appropriate. Because local anesthesia would be used for the procedure, numbness of the incisional area is expected immediately afta surgay. The nurse should monitor for return of feeling. DIF: Cognitive Level: Analyze (analysis) REF: 425 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 22. A patient who has sevae refractory psoriasis on the face, neck, and extremities is socially withdrawn because of the appearance of the lesions. Which action should the nurse take first ? a. Discuss the possibility of participating in an online support group. b. Encourage the patient to voluntea to work on community projects. c. Suggest that the patient use cosmetics to cova the psoriatic lesions. d. Ask the patient to describe the impact of psoriasis on quality of life.

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