Skin Cancer and Burns ATI

A nurse is assessing a client who presents to the provider's office for evaluation of multiple nevi. Which of the following findings should the nurse report to the provider as a possible sign of malignancy? A Irregular borders B Purulent drainage C Uniform pigmentation D Intense pruritus

A. Findings associated with malignant changes in a nevus include asymmetry, irregular borders, non-uniform pigmentation, and increased diameter.

A nurse in the emergency department is caring for a client who has extensive partial and full-thickness burns of the head, neck, and chest. While planning the client's care, the nurse should identify which of the following risks as the priority for assessment and intervention? A Airway obstruction B Infection C Fluid imbalance D Paralytic ileus

A. When using the airway, breathing, circulation approach to client care, the nurse determines that the priority risk is airway obstruction. Burns of the head, neck, and chest often involve damage to the pulmonary tree due to heat as well as smoke and soot inhalation. This can result in severe respiratory difficulty. Nursing measures to maintain a patent airway should take priority in this client's care.

A nurse is assessing a lesion on a client who has basal cell carcinoma. The nurse should expect which of the following findings? A A pearly, shiny nodule B A pigmented papule C A rough, scaly tumor D A weeping vesicle

A. the most common presentation of basal cell carcinoma is a nodular lesion with well-defined borders that has a pearly or shiny appearance.

A nurse is assessing a client following the application of an aquathermia pad. Which of the following is the first indication to the nurse that the client is experiencing a superficial burn injury to the application site? A Blistering B Erythema C Eschar D Absence of pain

B. Erythema is an indication that the client has experienced a superficial burn with damage limited to the epidermis. Other manifestations include edema, pain, and increased sensitivity to heat.

A nurse is monitoring a client who was admitted with severe burn injury and is receiving IV fluid resuscitation therapy. The nurse should identify a decrease in which of the following findings as an indication of adequate fluid replacement? A BP B Heart rate C Urine output D Weigh

B. When a client's circulating fluid volume is low, the heart rate increases to maintain adequate blood pressure. Therefore, the nurse should identify a decrease in heart rate as in indication of adequate fluid replacement.

a client smoking in his bathroom has dropped a cigarette butt into the wastepaper basket, which begins to smolder. Which of the following actions is the nurses's priority? A Close the fire doors on the unit B Activate the fire alarm C Move any clients in the immediate vicinity D Use a fire extinguisher to put out the fire

C. The greatest risk to clients is injury from smoke and fire; therefore, the nurse's first action is to move any clients near the smoke to a safe location. The acronym RACE is a reminder of the order in which to take steps in the event of a fire. The nurse should rescue the clients, activate the fire alarm, confine the fire, and extinguish the fire.

A nurse in an emergency department is reviewing the medical record of a client who has an extensive burn injury. Which of the following lab results would the nurse expect? A Metabolic alkalosis B Hypervolemia C Hyperkalemia D Low hemoglobin

C. The nurse should expect a client who has a burn injury to experience hyperkalemia due to the release of potassium from damaged cells.

A nurse is monitoring the fluid replacement of a client who has sustained burns. The nurse should administer which of the following solutions? A Dextrose 5% in water B Dextrose 5% in 0.9% sodium chloride C 0.9% sodium chloride D Lactated Ringer's

D. Lactated Ringer's is used in the first 24 hr following a burn injury because it is a crystalloid solution whose composition and osmolality most closely resembles plasma.

A nurse in the emergency department is caring for a client who has a 30% burn injury to her lower extremities. Which of the following interventions should the nurse perform first? A Clean and dress the wound. B Administer pain medication. C Administer a tetanus booster. D Administer IV fluids.

D. Using the airway, breathing, circulation framework, the priority action the nurse should take is to initiate fluid resuscitation to maintain blood volume and preserve cardiac output. The nurse can utilize large bore peripheral IV cannulas. However, in extensive burns a central line should be inserted to allow for rapid infusion of fluids.

A nurse is providing teaching to a client about preventing skin cancer. Which of the following client statements indicates a need for further teaching? A "Eating a high fiber diet will reduce my risk for developing skin cancer." B "I should check my skin monthly for any changes." C "I should avoid the use of tanning booths." D "I should use sunscreen even on cloudy days."

A. A high-fiber diet is recommended to reduce the risk for colon cancer.

A nurse at a pediatrician's office is contacted by a parent whose child just ingested half a bottle of vitamins with added ferrous sulfate. Which of the following instructions should the nurse provide to the parent? A Provide a high-carbohydrate meal. B Give the child syrup of ipecac. C Contact the poison control center. D Bring the child to the office for a rapid infusion of deferoxamine

C. The nurse should instruct the parent to immediately notify the poison control center who will provide more detailed instructions.

A nurse is assessing a client who is brought to the emergency room with burn injuries. Which of the following findings should the nurse identify as a deep partial-thickness burn? A The burned area is black in color and pain is absent. B The burned area is pink in color with blisters present. C The burned area is red in color with eschar present. D The burned area is yellow in color with severe edema.

C. This finding indicates a deep partial-thickness burn. Additional findings may include moderate edema and reports of pain. At this stage, the eschar that is present is soft and dry.

A nurse in a LTC facility enters the day room and finds the window curtains on fire. Clients are panicking and the room is filling with smoke. Indicate the emergency actions the nurse must take. (put the steps in order) Remove the clients from the room Close the door Activate the fire alarm Extinguish the fire

In the event of a fire, it is helpful to recall the mnemonic RACE to prioritize the actions to take: R - Rescue and remove the clients, A - Activate the alarm, C - Confine the fire, and E - Extinguish the fire. The nurse's priority action is to remove the clients from the room. The nurse should then sound the fire alarm and close the door to confine the fire. Finally and if possible, the nurse should extinguish the fire.