Evolve: Integumentary

The nurse is providing postoperative care for a client that had choledocholithotomy. After identifying that the skin around the client's T-tube is raw and excoriated, the nurse plans to:

Use a skin barrier around the tube's exit site

Two days after a severely burned client is admitted to the hospital, the client begins to exhibit restlessness. The nurse determines that this most likely indicates that the client is developing:

Cerebral hypoxia

The nurse stops at an accident scene to administer emergency care for a person who has sustained partial- and full-thickness burns to the chest, right arm, and upper legs as the result of a car fire. What should the nurse do first when caring for this person?

Wrap the person in a clean, dry sheet

A nurse is caring for a client with full-thickness burns of the anterior trunk and thigh. During the first two to three days after the burn to monitor fluid balance, it is important for the nurse to assess the:

Urinary output every hour

A client who sustained a burn injury involving 36% of the body surface area is receiving hydrotherapy. What is the best nursing intervention when providing wound care?

Use a consistent approach to care and encourage participation.

A client who is to receive external radiation therapy says to the nurse, "My family said that I will get a radiation burn." What is the nurse's best response?

"A localized skin reaction usually occurs."

A client with a full-thickness burn receives an allograft. Several days later the client points out that the graft is coming off at the edges. What is the nurse's best response?

"It is a temporary graft; it is expected to fall off."

A client with third-degree burns asks a nurse, "Why do I need a temporary pigskin graft?" What is the nurse's best response?

"It relieves pain while promoting rapid healing."

An adolescent girl who has sustained deep partial-thickness burns of the face because of excessive exposure to the sun exclaims, "Prom night is only four weeks away. I'll never be healed!" What is the nurse's best response?

"Recovery will take approximately three weeks."

A client with burns tells the nurse that the primary health care provider stated that skin grafts would be required. The client asks when the procedure will be performed. The most appropriate nursing response is:

"Tell me what your primary health care provider said about the graft procedure."

An older client is brought to the hospital by a family member because of deep partial-thickness burns on the arms and hands. The client protests being hospitalized and asks, "Why can't I just go home and have my spouse care for me?" What is the best response by the nurse?

"You may heal more slowly because of your age, and you may need the special care and equipment available in the hospital."

A person sustains severe burns of the arms and is waiting for emergency services to arrive. A nurse bystander responds to the scene. Another bystander is getting ready to apply butter to the burns, stating that it will provide soothing relief. An appropriate response by the nurse is, "I wouldn't advise putting the butter on. Our focus should be on:

... covering up the victim with one of those tablecloths."

A client is admitted for treatment of partial- and full-thickness burns of the entire right lower extremity and the anterior portion of the right upper extremity. Performing an immediate appraisal, using the Rule of Nines, what is the percent of body surface area burned?

22.5%

A health care provider prescribes 2 L of intravenous (IV) fluid to be administered every 12 hours to a client who sustained a burn injury. The drop factor of the tubing is 10 gtts/mL. The nurse should set the flow rate at how many drops per minute? Record the answer using a whole number. ___ gtts/min

28

A burn victim has waxy white areas interspersed with pink and red areas on the chest and all of both arms. The nurse calculates that the percentage of total body surface area (TBSA) on which the client has sustained burns is:

36

The nurse uses the rule of nines to estimate the percentage of the burn surface area on a client who has burns covering the entire surface of both arms, the posterior trunk, the genitals, and the left leg. The nurse estimates the surface area to be?

55

The nurse is caring for a client with wound dressings to the burns on 55% of the body. The dressing changes are very painful according to the client and the client rates them 7/10 on the pain scale. The client has morphine 2 mg to be administered by mouth every 2 hours as needed. When planning the client's care, the nurse should administer the medication:

60 minutes before the dressing change.

A client is burned on the anterior part of both legs, from the knees to the feet. The nurse uses the Rule of Nines to assess the percentage of total body surface area (TBSA) burned. What percentage should the nurse document in the client's hospital record?

9%

A client is receiving total parenteral nutrition via a central venous access catheter. When providing care to the site, the nurse should wear:

A mask and sterile gloves

A client is recovering from full-thickness burns and the nurse provides counseling on how to best meet nutritional needs. When which foods are selected does the nurse identify that the client understands the teaching?

Cheeseburger and a malted milkshake

A person on the beach sustains a deep partial-thickness burn because of a severe sunburn. What is the best first-aid measure that a nurse should instruct the person to apply before seeking health care?

Cool, moist towels

The nurse is caring for a client who has been bitten by a raccoon. The client states, "Where I live, there seems to be raccoons and wild animals everywhere." The nurse recalls that rabies can be described as:

An acute viral infection, characterized by convulsions and difficulty swallowing, that affects the nervous system

A nurse uses the Braden Scale to predict a client's risk for developing pressure ulcers. What data should the nurse use to determine a client's score on this scale? Select all that apply.

Anorexia Hemiplegia History of diabetes Urinary incontinence

The nurse is planning the care for a client with a body surface burn injury of 55%. The nurse understands that clients with burn injuries:

Are prone to poor healing because of a hypermetabolic state.

The nurse is caring for a client with burns and reviews the client's laboratory results: blood urea nitrogen (BUN) 30 mg/dL, creatinine 2.4 mg/dL, serum potassium 6.3 mEq/L, pH 7.1, Po2 90 mm Hg, and Hgb 7.4 g/dL. The nurse concludes that these findings indicate:

Azotemia

A client who was hospitalized with partial- and full-thickness burns over 30% of the total body surface area is to be discharged. The client asks the nurse, "How will my spouse be able to care for me at home?" How should the nurse interpret this statement?

Beginning realization of implications for the future

The nurse is assessing a client 12 hours after the client sustained a deep partial-thickness burn on the forearm. What characteristics should the nurse expect to identify when assessing the injured tissue?

Blistered and wet

A nurse is interviewing a client who was diagnosed with systemic lupus erythematosus (SLE). Which common responses to this disease can the nurse expect the client to exhibit? Select all that apply.

Butterfly facial rash Inflammation of the joints

A client receiving combination chemotherapy for treatment of metastatic carcinoma asks the nurse in the clinic why more than one type of drug is necessary. Which concept is most important to teach the client in relation to why drug cocktails are more effective than a single drug in cancer therapy?

Cellular growth cycle

A severely burned client has been hospitalized for two days. Until now recovery has been uneventful, but the client begins to exhibit extreme restlessness. What does the nurse conclude the client is most likely developing?

Cerebral hypoxia

The nurse is providing care for a client diagnosed with invasive cancer of the head of the pancreas that has had a permanent biliary drainage tube (T-tube) inserted to provide palliative care. Postoperatively, the nurse should care for the T-tube by:

Cleansing the area around the insertion site to prevent skin breakdown

The nurse is teaching first aid to a group of community members. A participant asks what first aid should be administered to a person who suffers extensive burns. An appropriate response by the nurse is to call 911 and:

Cover the burned areas with a bed sheet

A worker is involved in an explosion of a steam pipe and receives a scalding burn to the chest and arms. The burned areas are painful, mottled red, weeping, and edematous. Which should the nurse conclude is an appropriate classification for these burns?

Deep partial-thickness

A client is admitted with cellulitis of the left leg and a temperature of 103° F. The primary health care provider prescribes intravenous (IV) antibiotics. Before instituting this therapy, the nurse should:

Determine the client's allergies

A nurse uses the same pair of gloves to remove a soiled dressing and to apply a new sterile dressing. Another nurse has observed the dressing change procedure. What initial action should the observing nurse take?

Discuss the incident with the nurse.

A client sustains severe burns over 40% of the surface area of the body. The nurse is assigned to care for the client during the first 48 hours after the injury. What clinical finding does the nurse anticipate if the client develops water intoxication?

Disorientation with twitching

A nurse evaluates the condition of a client with burns of the upper body. Which assessment findings indicate potential respiratory obstruction? Select all that apply.

Dry cough Singed nasal hair Hoarse quality to the voice

A client with a parotid tumor and enlarged lymph nodes in the neck is undergoing radiation therapy on an outpatient basis. For what physiologic response to the radiation should the nurse assess the client during the return visit to the radiology department?

Dysphagia

A client has a fracture of the tibia and a cast is applied. When caring for the client, the nurse should:

Elevate the affected leg above the level of the heart

A farmer seeks medical care for a large crusty patch of skin on the cheek. The client states that even after using different remedies, it still bleeds easily and has not gotten better. From the client's history, the nurse suspects skin cancer because the major precipitating factor associated with skin cancer is:

Exposure to radiation

When caring for a client who has a burn in the emergent stage, which has the highest priority as part of an accurate burn assessment?

Extent of burn

A client is admitted with 50% of the body surface area burned. The nurse caring for the client 48 hours after admission reviews the client's laboratory results: urine specific gravity 1.015, urine output 50 mL/hr, hematocrit 32, albumin 3.6 g/dL, and pulmonary arterial wedge pressure 10 mm Hg. The nurse concludes that the data indicate that the:

Fluid therapy is successful

When caring for a client with a portable wound drainage system (Hemovac), the nurse takes into consideration that the physics principle underlying this drainage system is:

Fluids flow from an area of higher pressure to one of lower pressure

A nurse epidemiologist is responsible for wound consults at the hospital where a client has been admitted with an infected wound. The client asks, "What is the primary role of a nurse epidemiologist?" The nurse explains that the nurse epidemiologist:

Helps health care providers to control infections

A nurse is evaluating a client's fluid loss resulting from extensive burns. What is the most valuable blood test to use when monitoring a client's fluid loss?

Hematocrit

The nurse is caring for a client four days after the client was admitted to the hospital with burns on the trunk and arms. The nurse provides a dietary plan for the following day and includes:

High caloric intake, liberal potassium intake, and 3 grams of protein/kg/day

When a nurse is evaluating the condition of a client with burns of the upper body, a sign that indicates potential respiratory obstruction is:

Hoarse quality to the voice

A client is hospitalized for intravenous antibiotic therapy and an incision and drainage of an abscess that developed at the site of a puncture wound. When should the nurse begin to teach the client about how to care for the wound?

In the preoperative period

A nurse is preparing to change a client's dressing. The nurse recalls that the basis of surgical asepsis that is needed for this procedure is to:

Keep the area free of microorganisms

As part of the teaching plan for a client with scleroderma, the nurse addresses the need for special skin care and advises the client to:

Keep the skin well lubricated

A client is scheduled to receive irradiation to the chest wall after a tumor was removed from the client's lung. When teaching skin care to the client, the nurse emphasizes:

Keeping the skin dry to protect it from excoriation

A nurse is caring for a client during the first few hours after admission to the burn unit with partial-thickness burns of the trunk and head. Which potential problem is the least concern for the nurse during the emergent phase of a burn injury?

Leukopenia

A client with cellulitis of the leg asks why bed rest has been prescribed. The nurse explains that the primary purpose of bed rest for this client is to:

Limit muscle contractions that may force causative organisms into the bloodstream

A client with burns over 35% of the body complains of chilling. To promote client comfort, the nurse should:

Limit room drafts

The nurse is caring for a client that has been admitted with partial- and full-thickness burns over 25% of the total body surface area (TBSA). Lactated Ringers and 5% dextrose have been prescribed to be rapidly infused to:

Maintain blood volume

After surgery, a client has a portable wound drainage system in place. What nursing intervention promotes drainage?

Maintaining compression of the drainage system.

The nurse should wear what personal protective equipment when providing central venous access device site care?

Mask and sterile gloves

The nurse is caring for a client who returns from surgery with a catheter that is attached to a portable wound drainage system exiting from the surgical site. The principle underlying the function of a portable drainage system is:

Negative pressure

A nurse stops at the scene of an accident and finds a man with a deep laceration on his hand, a fractured arm and leg, and abdominal pain. The nurse wraps the man's hand in a soiled cloth and drives him to the nearest hospital. The nurse is:

Negligent and can be sued for malpractice

The nurse is caring for a client that had a colostomy three days ago. The primary nursing intervention for this client is to:

Observe drainage and the condition of the abdominal incision

How should a nurse prepare a client for cranial surgery?

Obtain the client's consent to shave the head

A client is admitted to the hospital with deep partial-thickness burns to both hands and forearms after an accident. How should the nurse apply the prescribed antimicrobial medication?

Place the medication directly on the burn wound in a thin layer using sterile gloves.

A client with a partial-thickness burn reports feeling chilled. What should the nurse do to limit this response?

Prevent drafts in the client's room

Which is the most difficult problem for the nurse to manage when meeting the needs of an extensively burned client three days after admission?

Severe pain

A client is admitted to the hospital after sustaining serious burns that involve a large surface of the skin. The nurse is caring for the client during the emergent phase after the injury. Which nursing objective is the priority during this phase?

Restore fluid volume

A nurse is assessing a client with a diagnosis of psoriasis. Which clinical findings should the nurse expect to observe? Select all that apply.

Scaly lesions Pruritic lesions Reddened papules

A nurse is assessing a client during the first 24 hours after a burn injury. Which sign indicates to the nurse that fluid replacement therapy is adequate?

Slowing of a previously rapid pulse

A nurse is caring for a client who had a skin graft applied over a full-thickness burn on the chest. Which observation of the donor site during the first 24 hours after surgery should be reported to the health care provider immediately?

Small amount of yellowish green oozing

A health care provider tells a client that vitamin E and beta-carotene are important for healthier skin. Which foods should the nurse recommend that are excellent sources of both of these substances?

Spinach and mangoes

A nurse is caring for a group of clients who are being considered for treatment with a negative pressure wound treatment device. The nurse should discuss this prescription with the primary health care provider when the client has which condition?

Stage IV pressure ulcer with eschar

A nurse is assessing the adequacy of a client's intravenous fluid replacement therapy during the first 2 to 3 days after sustaining full-thickness burns to the trunk and right thigh. What assessment will provide the nurse with the most significant data?

Urinary output every hour

A client who has an above-the-knee amputation is fitted for a prosthesis. Two days after using the prosthesis, a small blister develops on the residual limb near the healed incision. The nurse anticipates that the client will be advised to:

Stop using the prosthesis until the blister heals

The nurse identifies silvery scales on a client's elbows and knees. To help identify the origin of this rash, the nurse should assess the client's history of:

Stress in recent months

A client has a diagnosis of superficial partial-thickness burns. The client asks what layers of skin are involved with this type of burn. What is an appropriate nursing response?

The epidermis is damaged

In response to a client's question, the nurse explains the difference between partial-thickness (second-degree) burns and full-thickness (third-degree) burns. What information about partial-thickness burns should the nurse include in the discussion?

They are painful, reddened, and have blisters

A nurse is caring for a client who is admitted to the hospital for medical management of heart failure and severe peripheral edema. For which clinical indicators associated with unresolved severe peripheral edema should the nurse assess the client?

Tissue ischemia

A client with burns develops a wound infection. The nurse plans to teach the client that local wound infections primarily are treated with what type of antibiotics?

Topical

A client with psoriasis asks the nurse what can help this condition. Which should the nurse include in a teaching plan for this client?

Topical application of steroids

A nurse is caring for a client admitted for removal of basal cell carcinoma and reconstruction of the nose. About which contributing factor should the nurse question the client when collecting a health history?

Ultraviolet radiation exposure

Before administering preoperative medication to a client, the nurse plans to:

Verify the consent

When planning care to prevent deformities and contractures in a client with burns, the nurse expects to begin range-of-motion (ROM) exercises when the client's:

Vital signs are stable

A client had a colostomy surgery and is learning how to care for the skin around the stoma. What should the nurse include in the teaching plan for this client?

Wash the area gently with soap and water before applying an appliance

The nurse is providing education about care of the residual limb to a client that had a below-the-elbow amputation. The teaching should include:

Washing and drying the residual limb at least once a day

A client who sustained serious burns now has a stress ulcer. When caring for this client, what clinical indicators of shock should the nurse immediately report to the health care provider? Select all that apply.

Weakness Diaphoresis Tachycardia Cold extremities

When assessing a wound that is healing by secondary intention, the nurse can classify it according to its condition and color. How should the nurse classify a wound that exhibits some soft necrotic tissue with a semiliquid slough and exudate?

Yellow