NCLEX 10000 Integumentary Disorders
During the emergent (resuscitative) phase of burn injury, which finding indicates that the client requires additional volume with fluid resuscitation? a) serum creatinine level of 2.5 mg/dL (221 µmol/L) b) serum albumin level of 3.8 g/dL (38 g/L) c) little fluctuation in daily weight d) hourly urine output of 60 mL
serum creatinine level of 2.5 mg/dL (221 µmol/L) Correct Explanation: Fluid shifting into the interstitial space causes intravascular volume depletion and decreased perfusion to the kidneys. This would result in an increase in serum creatinine. Urine output should be frequently monitored and adequately maintained with intravenous fluid resuscitation that would be increased when a drop in urine output occurs. Urine output should be at least 30 mL/h. Fluid replacement is based on the Parkland or Brooke formula and also the client's response by monitoring urine output, vital signs, and CVP readings. Daily weight is important to monitor for fluid status. Little fluctuation in weight suggests that there is no fluid retention and the intake is equal to output. Exudative loss of albumin occurs in burns, causing a decrease in colloid osmotic pressure. The normal serum albumin is 3.5 to 5 g/dL (35 to 50 g/L).
A nurse is performing an admission assessment on a client entering a long-term care facility. She notices a broken area of skin that extends into the dermis on the client's coccyx. How should the nurse document this wound? a) Stage II pressure ulcer b) Stage III pressure ulcer c) Stage I pressure ulcer d) Stage IV pressure ulcer
Stage II pressure ulcer Correct Explanation: A stage II pressure ulcer is a break in the skin that extends into the epidermis or the dermis. A stage I pressure ulcer is area of nonblanchable redness that may become cyanotic. A stage III pressure ulcer extends into the subcutaneous tissue. A stage IV pressure ulcer extends into the muscle or bone; most of the true tissue damage isn't easily seen.
A teenager is admitted to the burn unit with third-degree burn injuries over more than 40% of the body. When administering IV fluids to the client within the first 48 hours of injury, what is the most important responsibility of the nurse? a) Carefully monitor the client for signs of fluid overload. b) Ensure a fluid volume sufficient to prevent shock. c) Assess patency of the IV site every 4 hours. d) Confirm that a large-bore catheter was inserted.
Ensure a fluid volume sufficient to prevent shock. Correct Explanation: Fluid management is fundamental when treating burn clients during the immediate post-trauma period. Adequate volumes of IV fluids are required to prevent shock in those with extensive burn injuries. Significantly higher volumes of IV fluids are used with burn clients than with other clients. The aim of fluid resuscitation is to restore and maintain adequate oxygen delivery to all tissues of the body following the loss of sodium, water, and proteins. There are several formulas that can be applied to determine fluid resuscitation needs. One example is the Parkland formula. The Parkland formula for the total fluid requirement in 24 hours is as follows: • 4 mL x TBSA (%) x body weight (kg) • 50% given in first 8 hours • 50% given in next 16 hours Children receive maintenance fluid, in addition, at an hourly rate of: A. 4 mL/kg for the first 10 kg of body weight, plus B. 2 mL/kg for the second 10 kg of body weight, plus C. 1 mL/kg for > 20 kg of body weight End point • Urine - adults: 0.5-1.0 mL/kg/hour • Urine - children: 1.0-1.5 mL/kg/hour
A teenager asks advice from a nurse about getting a tattoo. When the nurse is providing education, which statement about tattoos is a common misconception? a) Hepatitis B is a possible risk factor. b) Human immunodeficiency syndrome (HIV) is a possible risk factor. c) Tattoos are easily removed with laser surgery. d) Allergic response to pigments is a possible risk factor.
Tattoos are easily removed with laser surgery. Correct Explanation: A common misconception regarding tattoos is that tattoos can be removed. Removing a tattoo is not an easy process, and most people are left with a significant scar. Also, the cost is expensive and not covered by insurance. Because of the moderate amount of bleeding with a tattoo, both hepatitis B and HIV are potential risks if proper techniques are not followed. Allergic reactions are possible when establishments do not use Food and Drug Administration-approved pigments for tattoo coloring. Reactions can also occur in clients who are hypersensitive to the pigments or tools used.
A client presents with blistering wounds caused by an unknown chemical agent. How should the nurse intervene? a) Wash the wounds with soap and water and apply a barrier cream. b) Do nothing until the chemical agent is identified. c) Irrigate the wounds with water. d) Insert a 20-gauge I.V. catheter and infuse normal saline solution at 150 ml/hour.
rrigate the wounds with water. Explanation: The nurse should begin treatment by irrigating the wounds with water. Delaying treatment until the agent is identified allows the agent to cause further tissue damage.
A teenager is admitted to the burn unit with third-degree burn injuries over more than 40% of the body. When administering IV fluids to the client within the first 48 hours of injury, what is the most important responsibility of the nurse? a) Carefully monitor the client for signs of fluid overload. b) Confirm that a large-bore catheter was inserted. c) Assess patency of the IV site every 4 hours. d) Ensure a fluid volume sufficient to prevent shock.
Ensure a fluid volume sufficient to prevent shock. Correct Explanation: Fluid management is fundamental when treating burn clients during the immediate post-trauma period. Adequate volumes of IV fluids are required to prevent shock in those with extensive burn injuries. Significantly higher volumes of IV fluids are used with burn clients than with other clients. The aim of fluid resuscitation is to restore and maintain adequate oxygen delivery to all tissues of the body following the loss of sodium, water, and proteins. There are several formulas that can be applied to determine fluid resuscitation needs. One example is the Parkland formula. The Parkland formula for the total fluid requirement in 24 hours is as follows: • 4 mL x TBSA (%) x body weight (kg) • 50% given in first 8 hours • 50% given in next 16 hours Children receive maintenance fluid, in addition, at an hourly rate of: A. 4 mL/kg for the first 10 kg of body weight, plus B. 2 mL/kg for the second 10 kg of body weight, plus C. 1 mL/kg for > 20 kg of body weight End point • Urine - adults: 0.5-1.0 mL/kg/hour • Urine - children: 1.0-1.5 mL/kg/hou
A teenage client is admitted to the burn unit with burns over 49% of the body surface area, including the face and neck. Carbon particles are noted around the nose and mouth. The client is slightly confused, with reports of minor pain. When assessing the client, which of the following is an immediate priority for the nurse to evaluate? a) Emotional reaction to the fire b) Reports of pain c) Mental status changes d) Patency of airway
Patency of airway Correct Explanation: It is very likely that the client has had a smoke inhalation injury after suffering a severe burn greater than 20% of the total body surface area and having burns of the face and neck. The carbon particles observed around the nose and mouth would support this. Smoke inhalation can cause severe injury to the upper airway and lead to death.
A 10-year-old child is brought to the office with complaints of severe itching in both hands that's especially annoying at night. On inspection, the nurse notes gray-brown burrows with epidermal curved ridges and follicular papules. The physician performs a lesion scraping to assess this condition. Based on the signs and symptoms, what diagnosis should the nurse expect? a) Scabies b) Dermatophytosis c) Impetigo d) Contact dermatitis
Scabies Correct Explanation: Signs and symptoms of scabies include gray-brown burrows, epidermal curved or linear ridges, and follicular papules. Clients complain of severe itching that usually occurs at night. Scabies commonly occurs in school-age children. The most common areas of infestation are the finger webs, flexor surface of the wrists, and antecubital fossae.
The client phones the outpatient surgery center following skin biopsy on the left shoulder. The client states that the site continues to drain pinkish drainage and is uncomfortable. Which triage questions are appropriate to evaluate the client's concern? Select all that apply. a) "What is your pain level on a 0-10 pain scale?" b) "Did you have any other skin biopsies that day?" c) "How are you cleaning the area?" d) "On which day did you have the biopsy completed?" e) "When is your follow-up appointment?" f) "Can you describe the drainage that you see."
• "What is your pain level on a 0-10 pain scale?" • "Can you describe the drainage that you see." • "On which day did you have the biopsy completed?" • "How are you cleaning the area?" Correct Explanation: When triaging a client's concern following a surgical biopsy, it is most important for the nurse to obtain information about the site and post-operative care. Knowing the date of the surgery allows for the nurse to determine the amount and type of drainage which is normal for that stage of healing. Understanding the characteristics of the drainage helps the nurse assess if the drainage is from a healing process or from a potential infection. Assessing the pain level provides information of the inflammatory and infectious process. The nurse compares the client's pain rating with the rating scale typically noted for this procedure. Lastly, the nurse assesses how the wound is being cleaned. The nurse wants to assess understanding regarding the cleaning process.
A nurse provides preoperative education to a client scheduled to undergo elective surgery. The nurse includes instructions about proper skin care. Which client statement indicates the need for further education? a) "I'll shower before coming to the hospital on the day of the surgery." b) "On the morning of surgery, I won't use lotions or cosmetics." c) "On the morning of the surgery, I can shave my surgical area at home to save time." d) "I should begin to use an antibacterial soap a few days before my surgical procedure."
"On the morning of the surgery, I can shave my surgical area at home to save time." Correct Explanation: The client shouldn't shave the surgical area at home. Any necessary clipping of hair will be done at the surgical center. Allowing the client to shave the area with a razor could cause skin abrasions and subsequent infections
When assessing an elderly client, a nurse on the day shift notes redness in the sacral region. Close assessment reveals small breaks in the skin surface. The client says the area is tender and must have lost skin when a nursing assistant on the previous shift moved him. He tells the nurse, "The nursing assistant on the last shift was rough. I asked her to look at my backside, but she told me she was too busy." What should the nurse do first? a) Document her findings. b) Prepare a disciplinary warning for the nursing assistant. c) Prepare an incident report. d) Contact the shift supervisor.
Document her findings. Correct Explanation: The nurse must first document her assessment findings; timely documentation helps ensure accuracy. The nurse should notify the shift supervisor after completing the documentation. She must follow the chain of command.
Which of the following would provide the most effective emergency care for a burn victim at the accident site? a) Pouring cool water over the burned area. b) Applying clean, dry dressings to the area. c) Applying a mild antiseptic ointment to the area. d) Rinsing the area with a warm, mild soap solution.
Applying clean, dry dressings to the area. Incorrect Correct response: Pouring cool water over the burned area. Explanation: The recommended emergency treatment for a heat burn is immersion in cool water or application of clean, cool wet packs. This treatment helps relieve pain and diminishes tissue damage by cooling the tissue. The burn should be kept moist to prevent the dressing adhering to the wound.
The nurse is reading the progress notes for a client who has a pressure ulcer. Based on the nurse's note in the chart, what stage pressure ulcer does this client have? a) Unstageable. b) Stage I. c) Suspected deep-tissue injury. d) Stage II.
Stage II. Correct Explanation: A stage II pressure ulcer has visible skin breaks and possible discoloration. Penetrating to the subcutaneous fat layer, the sore is painful and visibly swollen. The ulcer may be characterized as an abrasion, blister, or shallow crater.
A female client is diagnosed with primary herpes genitalis. Which instruction should the nurse provide? a) "Apply sulconazole nitrate twice daily by massaging it gently into the lesions." b) "Apply one applicator of tioconazole intravaginally at bedtime for 7 days." c) "Apply one applicator of terconazole intravaginally at bedtime for 7 days." d) "Apply acyclovir ointment to the lesions every 3 hours, six times per day for 7 days."
"Apply acyclovir ointment to the lesions every 3 hours, six times per day for 7 days." Correct Explanation: A client with primary herpes genitalis should apply topical acyclovir ointment in sufficient quantities to cover the lesions every 3 hours, six times per day for 7 days.
A client is admitted to the hospital after sustaining burns to the chest, abdomen, right arm, and right leg. The shaded areas in the illustration indicate the burned areas on the client's body. Using the "rule of nines," estimate what percentage of the client's body surface has been burned. a) 45% b) 64% c) 27% d) 18%
45% Correct Explanation: According to the rule of nines, this client has sustained burns on about 45% of the body surface. The right arm is calculated as being 9%, the right leg is 18%, and the anterior trunk is 18%, for a total of 45%.
When planning care for a client with burns on the upper torso, which nursing diagnosis should take the highest priority? a) Impaired physical mobility related to the disease process b) Risk for infection related to breaks in the skin c) Impaired skin integrity related to disease process d) Ineffective airway clearance related to edema of the respiratory passages
Ineffective airway clearance related to edema of the respiratory passages Explanation: When caring for a client with upper torso burns, the nurse's primary goal is to maintain respiratory integrity. Therefore, Ineffective airway clearance related to edema of the respiratory passages should take the highest priority.
A nurse is providing care for a client who has a sacral pressure ulcer with a wet-to-damp dressing. Which guideline is appropriate for a wet-to-damp dressing? a) The wet-to-damp dressing should be tightly packed into the wound. b) A plastic sheet-type dressing should cover the wet dressing. c) The dressing should be allowed to dry out before removal. d) The dressing should keep the wound moist.
The dressing should keep the wound moist. Correct Explanation: A wet-to-damp saline dressing should always keep the wound moist
A client comes to the physician's office for treatment of severe sunburn. The nurse takes this opportunity to discuss the importance of protecting the skin from the sun's damaging rays. Which instruction best prevents skin damage? a) "Apply sunscreen even on overcast days." b) "Use a sunscreen with a sun protection factor of 6 or higher." c) "When at the beach, sit in the shade to prevent sunburn." d) "Minimize sun exposure from 1 to 4 p.m., when the sun is strongest."
"Apply sunscreen even on overcast days." Correct Explanation: Sunscreen should be applied even on overcast days, because the sun's rays are as damaging then as on sunny days.
A physician orders an emollient for a client with pruritus of recent onset. The client asks why the emollient should be applied immediately after a bath or shower. How should the nurse respond? a) "To prevent evaporation of water from the hydrated epidermis." b) "To prevent skin inflammation." c) "To minimize cracking of the dermis." d) "To make the skin feel soft."
"To prevent evaporation of water from the hydrated epidermis." Correct Explanation: The nurse should tell the client that applying an emollient immediately after taking a bath or shower prevents evaporation of water from the hydrated epidermis, the skin's upper layer.
In a client with burns on the legs, which nursing intervention helps prevent contractures? a) Elevating the foot of the bed b) Performing shoulder range-of-motion exercises c) Hyperextending the client's palms d) Applying knee splints
Applying knee splints Correct Explanation: Applying knee splints prevents leg contractures by holding the joints in a position of function.
During a routine examination of a client's fingernails, the nurse notes a horizontal depression in each nail plate. When documenting this finding, the nurse should use which term? a) Beau's line b) Splinter hemorrhage c) Clubbing d) Paronychia
Beau's line Correct Explanation: Beau's line is a horizontal depression in the nail plate. Occurring alone or in multiples, these depressions result from a temporary disturbance in nail growth.
A client who was bitten by a wild animal is admitted to an acute care facility for treatment of rabies. Which type of isolation does this client require? a) Strict b) Enteric c) Contact d) Respiratory
Contact Correct Explanation: A client with rabies requires contact isolation because the disease is highly transmissible through close or direct contact.
While caring for the client with a burn injury who is experiencing hypersecretion of gastric acid, the nurse should observe the client for: a) Gastrointestinal ulceration. b) Hiatal hernia. c) Gastric distention. d) Paralytic ileus.
Gastrointestinal ulceration. Correct Explanation: Gastrointestinal ulceration, also known as Curling's ulcer, occurs in about half of clients suffering from severe burns. The incidence of ulceration appears proportional to the extent of the burns and is believed to be due to hypersecretion of gastric acid and compromised gastrointestinal perfusion.
At an outpatient clinic, a medical assistant interviews a client and documents the findings. The staff nurse reads the progress notes above and begins planning client care based on which nursing diagnosis? a) Readiness for enhanced knowledge of skin care precautions related to benign mole. b) Fear related to potential diagnosis of malignant melanoma. c) Deficient knowledge related to potential diagnosis of basal cell carcinoma. d) Risk for impaired skin integrity related to potential squamous cell carcinoma.
Fear related to potential diagnosis of malignant melanoma. Correct Explanation: Documentation reveals that the client is anxious about the symptoms. These symptoms most closely resemble malignant melanoma. Therefore, fear related to potential diagnosis of malignant melanoma is the most appropriate nursing diagnosis.
Which nutritional deficiency may delay wound healing? a) Lack of vitamin E b) Lack of vitamin D c) Lack of vitamin C d) Lack of calcium
Lack of vitamin C Correct Explanation: Vitamins A, C, and K; pyridoxine; riboflavin; and thiamin are necessary for wound healing. Adequate protein intake is necessary for improving skin integrity. Vitamin D and calcium are necessary for bone healing. Vitamin E isn't necessary for wound healing.
When developing a teaching plan for a client with an infected decubitus ulcer, the nurse should tell the client that which factor is most important for healing? a) adequate circulatory status b) fluid intake of 1,500 mL/day c) balanced nutritional diet d) scheduled periods of rest
adequate circulatory status Explanation: Adequate circulatory status is the most important factor in the healing process of an infected decubitus ulcer. Blood flow to the area must be present to bring nutrients and prescribed antibiotics to the tissues
When assessing a client with partial-thickness burns over 60% of the body, which finding should the nurse report immediately? a) Complaints of intense thirst b) Moderate to severe pain c) Hoarseness of the voice d) Urine output of 70 ml the first hour
Hoarseness of the voice Correct Explanation: Hoarseness is indicative of injury to the respiratory system and could indicate the need for immediate intubation
What is the primary goal of nursing care during the emergent phase after a burn injury? a) Promote wound healing. b) Replace lost fluids. c) Control pain. d) Prevent infection.
Replace lost fluids. Correct Explanation: During the emergent phase of burn care, one of the most significant problems is hypovolemic shock. The development of hypovolemic shock can lead to impaired blood flow through the heart and kidneys, resulting in decreased cardiac output and renal ischemia. Efforts are directed toward replacing lost fluids and preventing hypovolemic shock.
When assessing a client who is incontinent for risk for developing a pressure ulcer, the nurse should note which factor that can most alter tissue tolerance and lead to the development of a pressure ulcer? a) the client's gender b) exposure to moisture c) presence of hypertension d) smoking
exposure to moisture Correct Explanation: Exposure to moisture can lead to maceration and the development of pressure ulcers. It is important for the client's skin to be kept clean and dry with prompt attention to cleanliness after incidents of incontinence
The nurse is evaluating the client's risk for having a pressure sore. Which is the best indicator of risk for the client's developing a pressure sore? a) nutritional status b) orientation status c) circulatory status d) mobility status
mobility status Correct Explanation: The client's mobility status is the best indicator of risk for development of a pressure sore.
The nurse is caring for a client who has severe burns on the head, neck, trunk, and groin areas. Which position would be most appropriate for preventing contractures? a) semi-Fowler's b) high Fowler's c) supine d) prone
supine Correct Explanation: Supine in extension is the position most likely to prevent contractures. Clients who have experienced burns will find a flexed position most comfortable. However, flexion promotes the development of contractures.
The nurse is planning care for an older adult with a pressure ulcer (see figure). What should the nurse do? Select all that apply. a) Reposition the client every 2 hours. b) Elevate the head of the bed to 50 degrees. c) Cover with protective dressing. d) Request an alternating-pressure mattress. e) Obtain daily cultures.
• Request an alternating-pressure mattress. • Reposition the client every 2 hours. • Cover with protective dressing. Correct Explanation: The client has a stage II pressure ulcer. The nurse should take measures to relieve the pressure, treat the local infection, and protect the wound. The nurse should keep the ulcer covered with a protective dressing. The client should turn every 2 hours and use an alternating-pressure mattress to relieve pressure on the buttocks. The head of the bed should be elevated no more than 30 degrees.
Which nursing interventions are effective in preventing pressure ulcers? Select all that apply. a) If the client uses a wheelchair, seat him or her on a rubber or plastic doughnut. b) Avoid raising the head of the bed more than 90 degrees. c) When turning the client, slide and avoid lifting him or her. d) Turn and reposition the client every 1 to 2 hours unless contraindicated. e) Clean the skin with warm water and a mild cleaning agent; then apply a moisturizer. f) Use pillows to position the client and increase comfort.
• Use pillows to position the client and increase comfort. • Turn and reposition the client every 1 to 2 hours unless contraindicated. • Clean the skin with warm water and a mild cleaning agent; then apply a moisturizer. Correct Explanation: Nursing interventions that are effective in preventing pressure ulcers include cleaning the skin with warm water and a mild cleaning agent, and then applying a moisturizer; lifting, rather than sliding, the client when turning to reduce friction and shear; avoiding raising the head of the bed more than 30 degrees, except for brief periods; repositioning and turning the client every 1 to 2 hours unless contraindicated; and using pillows to position the client and increase comfort. If the client uses a wheelchair, the nurse should offer a pressure-relieving cushion as appropriate. The nurse should not seat the client on a rubber or plastic doughnut, because these devices can increase localized pressure at vulnerable points
A nurse is assessing the left lower extremity of a client with type 2 insulin-requiring diabetes and cellulitis. What should the nurse do? a) Encourage the client to ambulate in the halls on the unit. b) Cleanse the left lower leg with perfumed liquid soap. c) Instruct the client to elevate the left leg when sitting in the chair. d) Massage the left leg with alcohol to stimulate circulation.
Instruct the client to elevate the left leg when sitting in the chair. Correct Explanation: The client has cellulitis and should elevate the affected area above heart level.
A client presents with blistering wounds caused by an unknown chemical agent. How should the nurse intervene? a) Irrigate the wounds with water. b) Wash the wounds with soap and water and apply a barrier cream. c) Insert a 20-gauge I.V. catheter and infuse normal saline solution at 150 ml/hour. d) Do nothing until the chemical agent is identified.
Irrigate the wounds with water. Correct Explanation: The nurse should begin treatment by irrigating the wounds with water
The nurse is caring for a comatose, older adult with stage III pressure ulcers over two bony prominences. Which intervention should be added to the plan of care? a) Place the client on a pressure redistribution bed. b) Administer pain medications as ordered. c) Turn the client every 2 to 4 hours. d) Place a foam pad on the existing mattress
Place the client on a pressure redistribution bed. Correct Explanation: A pressure redistribution bed will allow for constant motion of the client and prevent further breakdown
A client received burns to his entire back and left arm. Using the Rule of Nines, the nurse can calculate that he has sustained burns on what percentage of his body? a) 18% b) 9% c) 36% d) 27%
27% Correct Explanation: According to the Rule of Nines, the posterior trunk, anterior trunk, and legs each make up 18% of the total body surface. The head, neck, and arms each make up 9% of total body surface, and the perineum makes up 1%. In this case, the client received burns to his back (18%) and one arm (9%), totaling 27% of his body.
A client who was bitten by a wild animal is admitted to an acute care facility for treatment of rabies. Which type of isolation does this client require? a) Enteric b) Strict c) Contact d) Respiratory
Contact Explanation: A client with rabies requires contact isolation because the disease is highly transmissible through close or direct contact. Rabies isn't transmitted through the air, eliminating the need for strict isolation, which aims to prevent transmission of highly contagious or virulent infections spread by both air and contact. Respiratory isolation, which prevents transmission only through the air, isn't sufficient for a client with rabies. Enteric isolation is inappropriate because rabies isn't transmitted through direct or indirect contact with feces.
The nurse is using home telehealth monitoring to manage care for an 80-year-old who is home bound. The client spends most of the day in bed. Two months ago, the nurse detected sacral redness from friction and shearing force of being in bed. Last month, the client had increased sacral redness, and the area was classified as a stage I pressure ulcer. On this visit, the nurse is assessing the sacral area using a video camera. The nurse compares the site from a visit made 1 month ago (see figure part A) to the assessment made at this visit (see figure part B). Upon comparing the change of the pressure ulcer from this visit to the previous visit, what should the nurse do first? a) Instruct the home health aide to reposition the client every 2 hours while the client is awake. b) Make a home visit to verify the changes in the ulcer. c) Contact the health care practitioner (HCP) to request a hydrocolloid dressing. d) Ask the client's daughter to purchase a foam mattress.
Contact the health care practitioner (HCP) to request a hydrocolloid dressing. Correct Explanation: The pressure ulcer has changed from stage I to stage II and requires the use of a protective dressing.
When assessing an elderly client, a nurse on the day shift notes redness in the sacral region. Close assessment reveals small breaks in the skin surface. The client says the area is tender and must have lost skin when a nursing assistant on the previous shift moved him. He tells the nurse, "The nursing assistant on the last shift was rough. I asked her to look at my backside, but she told me she was too busy." What should the nurse do first? a) Document her findings. b) Contact the shift supervisor. c) Prepare an incident report. d) Prepare a disciplinary warning for the nursing assistant.
Document her findings. Explanation: The nurse must first document her assessment findings; timely documentation helps ensure accuracy. The nurse should notify the shift supervisor after completing the documentation. She must follow the chain of command.
A nurse is changing a dressing and providing wound care. Place the following activities in the correct order. 1 2 3 4 Assess the drainage in the dressing. Slowly remove the soiled dressing. Wash hands thoroughly. Put on latex gloves.
Wash hands thoroughly. Put on latex gloves. Slowly remove the soiled dressing. Assess the drainage in the dressing. Correct Explanation: The correct order for a dressing change involves the nurse washing her hands, putting on gloves, removing the dressing, and observing the drainage.
The nurse should turn the client on bed rest every 2 hours to prevent the development of pressure ulcers. In addition, the nurse should: a) monitor the white blood cell count. b) monitor serum albumin. c) insert an indwelling urinary catheter. d) have the client walk at least twice a day.
monitor serum albumin. Correct Explanation: The nurse should monitor the client's serum albumin. A decreased serum albumin indicates malnutrition and is considered a risk factor in the development of pressure ulcers
The nurse should turn the client on bed rest every 2 hours to prevent the development of pressure ulcers. In addition, the nurse should: a) monitor the white blood cell count. b) monitor serum albumin. c) insert an indwelling urinary catheter. d) have the client walk at least twice a day.
monitor serum albumin. Correct Explanation: The nurse should monitor the client's serum albumin. A decreased serum albumin indicates malnutrition and is considered a risk factor in the development of pressure ulcers.
A client is admitted to the Emergency Department with a full thickness burn to the right arm. Upon assessment, the arm is edematous, fingers are mottled, and radial pulse is now absent. The client states that the pain is 8 on a scale of 1 to 10. The nurse should: a) administer morphine sulfate IV push for the severe pain. b) continue to assess the arm every hour for any additional changes. c) instruct the client to exercise his fingers and wrist. d) call the health care provider (HCP) to report the loss of the radial pulse.
call the health care provider (HCP) to report the loss of the radial pulse. Correct Explanation: Circulation can be impaired by circumferential burns and edema, causing compartment syndrome. Early recognition and treatment of impaired blood supply is key. The HCP should be informed since an escharotomy (incision through full-thickness eschar) is frequently performed to restore circulation.
A client is recovering from an infected abdominal wound. Which foods should the nurse encourage the client to eat to support wound healing and recovery from the infection? a) cheeseburger and french fries b) cheese omelet and bacon c) gelatin salad and tea d) chicken and orange slices
chicken and orange slices Correct Explanation: Protein and vitamin C are particularly important in promoting wound healing and recovery from infection. A diet high in carbohydrates is also essential. Because the client with an infection commonly does not feel like eating, it is important that what the client eats should be nutritious. Chicken and orange slices would help meet the client's protein and vitamin needs.
Which client should receive a shingles vaccine? A client who: a) is older than 60 years. b) has never had chickenpox. c) has a compromised immune system. d) is at risk for genital herpes.
is older than 60 years. Correct Explanation: People older than 60 years should receive shingles vaccine to prevent the disease. The vaccine is not effective for genital herpes. The vaccine can be given to persons who have or have not had chickenpox. The vaccine is not advised for persons with a compromised immune system, for example those receiving chemotherapy or radiation therapy
While assessing the skin of a 45-year-old, fair-skinned female client, the nurse notes a lesion on the medial aspect of her lower leg. It has irregular borders, with various shades of black and brown. The client states that the lesion itches occasionally and bled slightly a few weeks ago. She also reveals a history of sunburns. Based on these signs and symptoms, the nurse suspects: a) basal cell carcinoma. b) squamous cell carcinoma. c) actinic keratoses. d) melanoma.
melanoma. Correct Explanation: The "ABCDs" of melanoma are Asymmetry of the lesion, Borders that are irregular, Colors that vary in shades, and increased Diameter. Fair skin with a history of sunburn and the location of the lesion on the leg (the most common site in women) suggest melanoma.
During nursing rounds, a nurse checks on a client on bed rest who reports an itchy rash. The nurse assesses the client's skin for erythematous, slightly edematous areas on the client's back, posterior lower legs, and posterior elbows. The physician's diagnosis is an allergic contact dermatitis. Which teaching points about contact dermatitis are correct? Select all that apply. a) This is an allergic reaction. b) Oatmeal (Aveeno) baths are a good treatment for a rash of this type because of the large area involved. c) Based on the location, it is likely that detergents in the bed linens caused the rash. d) Washing with antibacterial soap will help the rash. e) The disorder is contagious. f) The skin is infected wherever the rash has developed.
• Based on the location, it is likely that detergents in the bed linens caused the rash. • Oatmeal (Aveeno) baths are a good treatment for a rash of this type because of the large area involved. • This is an allergic reaction. Correct Explanation: Contact dermatitis is classified as a reaction to an allergen and can appear when skin, especially if it's moist from perspiring or other reasons, remains in contact with an irritant for an extended time. It is a hypersensitivity reaction but usually requires extended contact. This client has a presentation often seen when clients remain in bed, perspiring on detergent-cleansed bed linens or gowns. This type of sensitivity to detergents may not have produced a reaction with a shorter time contact. The rash is not contagious or infectious, although areas may become exudative and crusted. Treatment varies according to the intensity of the skin reaction and other factors, but oatmeal (Aveeno) baths are frequently prescribed.
During the first 48 to 72 hours of fluid resuscitation therapy after a major burn injury, the I.V. infusion rate will be adjusted by evaluating the client's: a) Hourly body temperature. b) Hourly urine specific gravity. c) Daily body weight. d) Hourly urine output.
Hourly urine output. Correct Explanation: During the first 48 to 72 hours of fluid resuscitation therapy, hourly urine output is the most accessible and generally reliable indicator of adequate fluid replacement. Fluid volume is also assessed by monitoring mental status, vital signs, peripheral perfusion, and body weight. Pulmonary artery end-diastolic pressure (PAEDP) and even central venous pressure (CVP) are preferred guides to fluid administration, but urine output is best when PAEDP or CVP are not used.
When instructing the client with severe burns about proper nutrition, the nurse should encourage the client to choose which of the following meals for lunch? a) Hamburger, orange, coffee. b) Roast beef sandwich, milkshake, cottage cheese. c) Chicken breast, salad, iced tea. d) Pasta salad, carrots, milk.
Roast beef sandwich, milkshake, cottage cheese. Correct Explanation: A roast beef sandwich, milkshake, and cottage cheese would provide the burn victim with the extra protein and calories needed for healing.
To treat a client with acne vulgaris, the physician is most likely to order which topical agent for nightly application? a) Fluorouracil b) Zinc oxide gelatin c) Minoxidil d) Tretinoin
Tretinoin Correct Explanation: Tretinoin is a topical agent applied nightly to treat acne vulgaris. Minoxidil promotes hair growth. Zinc oxide gelatin treats stasis dermatitis on the lower legs. Fluorouracil is an antineoplastic topical agent that treats superficial basal cell carcinoma.
A nurse is assessing a client admitted with deep partial-thickness and full-thickness burns on the face, arms, and chest. Which finding indicates a potential problem? a) Partial pressure of arterial oxygen (PaO2) value of 80 mm Hg b) Urine output of 20 ml/hour c) White pulmonary secretions d) Rectal temperature of 100.6° F (38° C)
Urine output of 20 ml/hour Correct Explanation: A urine output of less than 30 ml/hour in a client with burns indicates a deficient fluid volume. This client's PaO2 value falls within the normal range (80 to 100 mm Hg). White pulmonary secretions are normal. The client's rectal temperature isn't significantly elevated, and the slight increase in temperature probably results from the deficient fluid volume.
An advantage of using biologic burn grafts such as porcine (pigskin) grafts is that they: a) encourage formation of tough skin. b) provide for permanent wound closure. c) promote the growth of epithelial tissue. d) facilitate development of subcutaneous tissue.
promote the growth of epithelial tissue. Correct Explanation: Biologic dressings such as porcine grafts serve many purposes for a client with severe burns. They enhance the growth of epithelial tissues, minimize the overgrowth of granulation tissue, prevent loss of water and protein, decrease pain, increase mobility, and help prevent infection.
During the emergent (resuscitative) phase of burn injury, which finding indicates that the client requires additional volume with fluid resuscitation? a) hourly urine output of 60 mL b) serum albumin level of 3.8 g/dL (38 g/L) c) serum creatinine level of 2.5 mg/dL (221 µmol/L) d) little fluctuation in daily weight
serum creatinine level of 2.5 mg/dL (221 µmol/L) Correct Explanation: Fluid shifting into the interstitial space causes intravascular volume depletion and decreased perfusion to the kidneys. This would result in an increase in serum creatinin
A 29-year-old woman is concerned about her personal risk factors for malignant melanoma. She is upset because her 49-year-old sister was recently diagnosed with the disease. After gathering information about the client's history of sun exposure, the nurse's best response would be to explain that: a) some melanomas have a familial component and she should seek medical advice. b) she should not worry, because she did not experience severe sunburn as a child. c) her personal risk is low because most melanomas occur at age 60 or later. d) her personal risk is low because melanoma does not have a familial component.
some melanomas have a familial component and she should seek medical advice. Correct Explanation: Malignant melanoma may have a familial basis, especially in families with dysplastic nevi syndrome. First-degree relatives should be monitored closely. Malignant melanoma occurs most often in the 20- to 45-year-old age-group
A client is receiving fluid replacement with lactated Ringer's after 40% of the body was burned 10 hours ago. The assessment reveals temperature 97.1° F (36.2° C), heart rate 122 bpm, blood pressure 84/42 mm Hg, central venous pressure (CVP) 2 mm Hg, and urine output 25 mL for the last 2 hours. The IV rate is currently at 375 mL/h. Using the SBAR (Situation-Background-Assessment-Recommendation) technique for communication, the nurse calls the health care provider (HCP) with a recommendation for: a) fresh frozen plasma b) dextrose 5% c) IV rate increase d) furosemide
IV rate increase Correct Explanation: The decreased urine output, low blood pressure, low CVP, and high heart rate indicate hypovolemia and the need to increase fluid volume replacement
Which client is at greatest risk for inadequate nutrition? a) the client who is breastfeeding b) the client recovering from a femur fracture c) the client with diabetetic peripheral neuropathy d) the client with burns to 45% of the body
the client with burns to 45% of the body Correct Explanation: With illness or injury, there is a need to heal or recover. To accomplish this, the client must consistently consume adequate nutrition (and protein) to maintain a positive nitrogen balance, and to experience necessary growth and/or healing. The client with burns has the greatest nutritional needs, due to the extent of the injury
Which factor would have the least influence on the survival and effectiveness of a burn victim's porcine grafts? a) use of analgesics as necessary for pain relief b) adequate vascularization in the grafted area c) absence of infection in the wounds d) immobilization of the area being grafted
use of analgesics as necessary for pain relief Correct Explanation: Analgesic administration to keep a burn victim comfortable is important but is unlikely to influence graft survival and effectiveness.
A client who was transferred from a long-term care facility is admitted with dehydration and pneumonia. Which nursing interventions can help prevent pressure ulcer formation in this client? Select all that apply. a) Tuck bed covers tightly into the foot of the bed. b) Reposition the client every 2 hours. c) Perform range-of-motion exercises. d) Encourage the client to eat a well-balanced diet. e) Use commercial soaps to keep the skin dry.
• Reposition the client every 2 hours. • Encourage the client to eat a well-balanced diet. • Perform range-of-motion exercises. Correct Explanation: To prevent pressure ulcer formation, the nurse should turn and reposition the client every 2 hours, perform range-of-motion exercises, avoid using commercial soaps that dry or irritate skin, avoid tucking covers tightly into the foot of the bed, and encourage the client to eat a well-balanced diet.
During the emergent stage of burn management for a client with burns of 30 percent of the body the nurse should assess the client for which of the following? Select all that apply. a) Hypoglycemia. b) Increased hematocrit. c) Hyponatremia. d) Hyperkalemia. e) "Fever spikes."
• Hyperkalemia. • Increased hematocrit. • "Fever spikes." Explanation: In the emergent phase of burn management, hyperkalemia develops as a result of the destruction of red blood cells. The hematocrit is increased in response to the plasma loss that has occurred and the resulting hemoconcentration. Initially, hyponatremia may occur as sodium shifts into the interstitial spaces. "Fever spikes" of 102 to 103 degrees F (38.9 to 39.4 degrees C) are common during this stage. The client will have hyperglycemia due to decreased levels of insulin production.
On the fourth day after surgery, a client has a postoperative wound infection. Which of the following should the nurse assess? Select all that apply. a) Redness and swelling beyond the incision line. b) 89% segmented neutrophils. c) Incisional pain greater than on day 2. d) Total white blood count (WBC) 10,000/mm (10 X 109/L). e) Temperature of 102° F (38.9° C).
• Redness and swelling beyond the incision line. • Temperature of 102° F (38.9° C). • 89% segmented neutrophils. Explanation: WBC count should be above normal (4,500 to 11,000/mm [4.5 to 11 X 109/L]) with an acute infection or inflammatory response such as a postoperative wound infection. Redness and swelling beyond the incision line is expected with a wound infection. An elevated temperature such as 102° F (38.9° C) on the third to fourth postoperative day indicates an infection process rather than an inflammatory process. An elevation in the segmented neutrophils demonstrates that the most mature WBCs have responded to the invading bacteria at the incision site, which is an expected response. Typically, postoperative pain begins to lessen by the 4th day.
A child is brought to the emergency department with a full-thickness burn involving the epidermis, dermis, and underlying subcutaneous tissue, but does not report pain at this time. Which of the following statements by the nurse are correct about this type of burn? Select all that apply. a) This is a severe burn and nerve endings have been destroyed. b) Rehabilitation and skin grafting will be necessary. c) Pain medication has been administered orally and was effective. d) This is a superficial burn, so no pain is present. e) The child must be monitored for signs of fluid shift
• This is a severe burn and nerve endings have been destroyed. • The child must be monitored for signs of fluid shift. • Rehabilitation and skin grafting will be necessary. Correct Explanation: This is an example of a third-degree burn, which is very serious. This child must be carefully monitored for complications. The fact that there is no pain is due to the destruction of the nerve endings. Fluid shift can occur and result in shock. A burn of this degree will also require a long rehabilitation with skin grafting.
In an industrial accident, a client who weighs 155 lb (70 kg) sustained full-thickness burns over 40% of his body. He's in the burn unit receiving fluid resuscitation. Which finding shows that the fluid resuscitation is benefiting the client? a) A urine output consistently above 40 ml/hour (40 mL/hour) b) Body temperature readings all within normal limits c) A weight gain of 4 lb (2 kg) in 24 hours d) An electrocardiogram (ECG) showing no arrhythmias
A urine output consistently above 40 ml/hour (40 mL/hour) Correct Explanation: In a client with burns, the goal of fluid resuscitation is to maintain a mean arterial blood pressure that provides adequate perfusion of vital structures. If the kidneys are adequately perfused, they will produce an acceptable urine output of at least 0.5 ml/kg/hour. Thus, the expected urine output of a 155-lb (70 kg) client is 35 ml/hour, and a urine output consistently above 40 ml/hour is adequate. Weight gain from fluid resuscitation isn't a goal. In fact, a 4-lb (2 kg) weight gain in 24 hours suggests third spacing.
Sudoriferous glands secrete which type of substance? a) Cerumen b) Hormones c) Sweat d) Oil
Sweat Correct Explanation: Sudoriferous glands are long, coiled tubes that secrete sweat through a duct on the body's surface. Sebaceous glands secrete oil (sebum). Endocrine glands secrete hormones. Together, ceruminous and sebaceous glands secrete cerumen.
A nurse is preparing a care plan for a client burned over 36% of his body 2 days previously. Which clinical manifestation indicates that the client has progressed into the intermediate phase of burn care? a) The client's urinary output has fallen below 30 ml/hour. b) The client's serum sodium levels are elevated. c) The client exhibits metabolic alkalosis. d) The client's complete blood count readings reflect a reduced hematocrit.
The client's complete blood count readings reflect a reduced hematocrit. Explanation: During the intermediate phase of burn care, the client's hematocrit should diminish as a result of hemodilution, which occurs as the fluids shift back into the circulating blood volume from the tissues. In the intermediate phase of burn care, the client will experience serum sodium deficits.
An advantage of using biologic burn grafts such as porcine (pigskin) grafts is that they: a) provide for permanent wound closure. b) encourage formation of tough skin. c) facilitate development of subcutaneous tissue. d) promote the growth of epithelial tissue.
promote the growth of epithelial tissue. Correct Explanation: Biologic dressings such as porcine grafts serve many purposes for a client with severe burns. They enhance the growth of epithelial tissues, minimize the overgrowth of granulation tissue, prevent loss of water and protein, decrease pain, increase mobility, and help prevent infection. They do not encourage growth of tougher skin, provide for permanent wound closure, or facilitate growth of subcutaneous tissue
