CH 75 Saunders; ATI Questions; NCLEX Basic Book Nursing

An adult client was burned as a result of an explosion. The burn initially affected the clients entire face (the anterior half of the head) and the upper half of the anterior torso, and there were circumferential burns to the lower half of both arms. The clients clothes caught fire and the client ran, which caused subsequent burn injuries of the posterior surface of the head and the upper half of the posterior torso. According to the rule of nines, what is the extent of this clients burn injury?

36%

A nurse is reviewing information about a new prescription or corticosteroid cream with a client who has mild psoriasis. Which of the following instructions should the nurse include? Select all that apply A. Apply an occlusive dressing after application. B. Apply three to four times a day C. Wear gloves after application to lesions on the hands D. Avoid applying in skin folds E. Use medication continuously over a period of several months

A. Apply an occlusive dressing after application. C. Wear gloves after application to lesions on the hands D. Avoid applying in skin folds

The nurse is reviewing the health care record of a client with a legion that has been diagnosed as basal cell carcinoma. The nurse should expect which characteristics of this type of lesion to be documented in the clients record? Select all that apply A. Lesion has a waxy border B. An irregularly shaped lesion C. Papule, with a red, central crater D. A small papule with a dry, rough scale E. A firm nodular lesion topped with a crust

A. Lesion has a waxy border B. An irregularly shaped lesion

A nurse is reinforcing a teaching with a client who has a history of psoriasis about photochemotherapy and ultraviolet light (PUVA) treatments. Which of the following instructions should the nurse include in the teaching? A. Apply vitamin A cream before each treatment B. Administer a psoralen medication before the treatment C. Use the treatment every evening. D. Remove the scales gently following each treatment

B. Administer a psoralen medication before the treatment

A nurse is reinforcing teaching with a female client on the use of calcipotriene topical medications for the treatment of psoriasis. Which of the following information should the nurse include? Select all that apply A. Recommended for facial lesions B. Expect a stinging sensation upon application C. Apply to the scalp D. Obtain a pregnancy test E. Limit application to skin folds

B. Expect a stinging sensation upon application C. Apply to the scalp D. Obtain a pregnancy test E. Limit application to skin folds

The nurse is assigned to care for a client with herpes zoster. Based on an understanding of the cause of this disorder, the nurse determines that this definitive diagnosis was made by which diagnostic test? A. Positive patch test B. Positive culture results C. Abnormal biopsy results D. Woods light examination indicative of infection

B. Positive culture results

The client arrives at the emergency department after a burn injury that occurred in their home basement and in an inhalation injury is suspected. Which should the nurse anticipate as being prescribed for the client? A. Oxygen via nasal cannula at 10L B. Oxygen via nasal cannula at 15L C. 100% oxygen via an aerosol mask D. 100% oxygen via tight-fitting, nonrebreather face mask

D. 100% oxygen via tight-fitting, nonrebreather face mask

A child has been treated for head lice but has remaining nits attached to the hair shaft. What should the nurse instruct the parent to do? A. Apply petroleum jelly B. Apply a hair cap to smother them C. Soak the hair in water D. Comb the hair with a fine tooth comb

D. Comb the hair with a fine tooth comb

The nurse is applying a topical corticosteroid to a client with eczema. The nurse apply the medication to which body area? Select all that apply. a. Back b. Axilla c. Eyelids d. Soles of the feet e. Palms of the hands

a. Back b. Soles of the feet e. Palms of the hands Rationale: topical corticosteroids can be absorbed into the systemic circulation. Absorption is higher from regions where the skin is especially permeable ( scalp, axilla, face, eyelids, neck, perineum, genitalia), and lower from regions where permeability is poor (back, palms, soles). The nurse should avoid areas of higher absorption to prevent systemic absorption.

A burn client is receiving treatments of topical mafenide acetate to the site of injury. the nurse monitors the clients, knowing that which finding indicates that a systemic effect has occurred? a. Hyperventilation b. Elevated blood pressure c. Local rash at burn site d. Local pain at burn site

a. Hyperventilation Rationale: mafenide acetate is a Carbonic anhydrase inhibitor and can suppress renal excretion of acid, thereby causing acidosis. Clients receiving this treatment should be monitored for signs of an acid base imbalance (hyperventilation). if this occurs, the medication will probably be discontinued for one to two days. Options three and four describe local rather than systemic effects. An elevated blood pressure may be expected from the pain that occurs with a burn injury.

The clinic performing an admission assessment on a client votes the client is taking azelaic acid period the nurse determines that which client complaint may be associated with the use of this medication? a. Itching b. Euphoria c. Drowsiness d. Frequent urination

a. Itching Rationale: azelaic acid is a topical medication used to treat mild to moderate acne. Adverse effects include burning, itching, stinging, redness of the skin, and hypo pigmentation of the skin in clients with a dark complexion. the effects noted in the other options are not specifically associated with this medication.

Salicylic acid is prescribed for a client with a diagnosis of psoriasis. the nurse monitors the client, knowing that which finding indicates the presence of systemic toxicity from this medication? a. Tinnitus b. Diarrhea c. Constipation d. Decreased respirations

a. Tinnitus Rationale: salicylic acid is absorbed readily through the skin, and systemic toxicity can result period symptoms include tinnitus, dizziness, hyperpnea comma and psychological disturbances period constipation and diarrhea are not associated with salicylism.

Silver sulfadiazine is prescribed for a client with a partial thickness burn and the nurse provides teaching about the medication. Which statement made by the client indicates a need for further teaching about the treatments? a. "The medication is an antibacterial." b. "The medication will help heal the burn." c. "The medication is likely to cause stinging every time it is applied." d. "The medication should be applied directly to the wound."

c. "The medication is likely to cause stinging every time it is applied." Rationale: silver sulfadiazine is an antibacterial that has a broad spectrum of activity against gram-negative bacteria gram positive bacteria, and yeast. It is applied directly to the wound to assistant healing. It does not cause stinging when applied.

The Camp nurse asked the children preparing to swim in the lake if they have applied sunscreen. The nurse reminds the children that chemical sunscreens are most effective when applied at which times? a. Immediately before swimming b. 5 minutes before exposure to the sun c. Immediately before exposure to the sun d. At least 30 minutes before exposure to the sun

d. At least 30 minutes before exposure to the sun. Rationale: sunscreens are most effective when applied at least 30 minutes before exposure to the sun so that they can penetrate the skin. All sunscreen should be reapplied after swimming or sweating.

Isotretinoin is prescribed for a client with severe acne. Before the administration of this medication, the nurse anticipates that which Laboratory test will be prescribed? 1. Potassium level 2. Triglyceride level 3. Hemoglobin A1C 4. Total cholesterol level

2. Triglyceride level Rationale: isotretinoin can Elevate triglyceride levels period blood triglyceride levels should be measured before treatment and periodically thereafter until the effect on triglycerides has been evaluated. There is no indication that isotretinoin effects potassium, hemoglobin A1c, or total cholesterol levels.

A client is prescribed hydroxyzine HCL for the treatment of puritus. What information should the nurse provide to the client? Select all that apply A. The medication may cause drowsiness B. Drink water, juice, and other fluids C. Use sunscreen when exposed to the sun D. Administer medication on an empty stomach E. Discontinue medications 1 week before skin testing

A. The medication may cause drowsiness B. Drink water, juice, and other fluids C. Use sunscreen when exposed to the sun

Which should the anticipated therapeutic outcome of an escharotomy procedure performed for a circumrerential arm burn? A. The return of distal pulses B. Decrease edema formation C. Brisk bleeding from the injury site D. The formation of granulation tissue

A. The return of distal pulses

A nurse is reinforcing teaching with the with the child who has a contact dermatitis. Which of the following information should the nurse include? A. Use fabric softener dryer sheets when drying the childs clothing B. Apply a warm, dry compress to the rash area C. Place the child in a bath with a colloidal oatmeal. D. Leave the child's hands uncovered during the night

C. Place the child in a bath with a colloidal oatmeal.

A client developed angioedema after taking lisinopril. What priority nursing action is essential when caring for this client? A. Start an IV B. Insert an indwelling catheter C. Apply antipriuritic lotion D. Maintain patent airway

D. Maintain patent airway

The evening nurse reviews the nursing documentation in the clients chart and notes that the day nurse has documented that the client has a stage 2 pressure injury in the sacral area? A. Intact skin B. The presence of tunneling C. A deep crater like appearance D. Partial thickness skin loss of the epidermis

D. Partial thickness skin loss of the epidermis

A client returns to the clinic for follow up treatment after a skin biopsy of a suspicious lesion that was performed a week ago. The biopsy report indicates that the lesion is a melanoma. The nurse understands that which characteristics describe this type of lesion? Select all that apply A. Metastasis is rare B. It is encapsulated C. It is highly metastatic D. It is characterized by local invasion E. Lesion is a nevus that has changed in color

C. It is highly metastatic E. Lesion is a nevus that has changed in color

A nurse is caring for a client who has a suspected viral skin lesion. Which of the following laboratory findings should the nurse anticipate the provider reviewing to confirm diagnosis? A. Potassium hydroxide (KOH) B. Diascopy C. Tzanck smear report D. Biopsy

C. Tzanck smear report

Silver sulfadiazine is prescribed for a client with a burn injury. Which laboratory finding requires the need for follow-up by the nurse? a. Glucose level of 99 mg/dL b. Magnesium level of 1.5 mEq/L c. Platelet level of 300,000 d. White blood cell count of 3000

d. White blood cell count of 3000 Rationale: silver sulfadiazine is used for the treatment of burn injuries. Adverse effects of this medication include rash and itching, blue green or gray skin discoloration, leukopenia, and interstitial nephritis. The nurse should monitor a complete blood count, particularly the white blood cells, frequently for the client taking this medication. If leukopenia develops, the healthcare provider is notified and the medication is usually discontinued. The white blood cell count noted an option for is indicative of leukopenia. The other laboratory values are not specific to this medication, and are also within normal limits.

The nurse is preparing to apply a moist dressing to a sacral pressure wound. What is a priority action by the nurse? A. Medicate with analgesics one half hour prior to the procedure. B. Have the client sign a consent form to perform the procedure. C. Document the procedure so that it wont be forgotten D. Remove the narcotic tissue with forceps

A. Medicate with analgesics one half hour prior to the procedure

A nurse is collecting data from a client who sustained deep partial-thickness and full thickness burns over 40 percent of his body 24hr ago. Which of the following findings should the nurse expect? Select all that apply A. Dyspnea B. bradycardia C. Hyperkalemia D. Hyponatremia E. Decreased hematocrit

A. Dyspnea C. Hyperkalemia D. Hyponatremia

A nurse is reinforcing teaching with a client on home care after culture for bacterial infection and cellulitis. Which of the following information should the nurse include? A. Bathe daily with moisturizing soap B. Apply antibacterial topical medication to the crusted exudate C. apply warm compresses to the affected area D. cover affected area with snug fitting clothing

C. apply warm compresses to the affected area

A nurse is assisting with the plan of care for an adult client who sustained severe burn injuries. Which of the following interventions should the nurse include in the plan of care? Select all that apply A. Limit visitors in the clients room B. Encourage fresh vegetables in the diet C. Increase protein intake D. Instruct the client to consume 2,000 calories/day E. Restrict fresh flowers in the room

A. Limit visitors in the clients room C. Increase protein intake E. Restrict fresh flowers in the room

A nurse in a providers office is collecting data from a client who has a severe sunburn. Which of the following classifications should the nurse use to document this burn? A. Superficial thickness B. Superficial partial thickness C. Deep partial thickness D. Full thickness

A. Superficial thickness

The nurse observes a client with a facial burns and suspects smoke inhalation. What observations lead the nurse to suspect this condition? Select all that apply A. The facial burns B. Singed nasal hairs C. Soot around nares D. Soot-stained sputum E. Report of pain at the burn site

A. The facial burns B. Singed nasal hairs C. Soot around nares D. Soot-stained sputum

The nurse reinforces instructions to a group of a clients regarding measures that will assist with the prevention of skin cancer. Which statement by a client indicates the need for further teaching? A. I need to wear sunscreen when participating in outdoor activities B. I need to avoid sun exposure before 10am to 4pm C. I need to wear a hat, opaque clothing, and sunglasses when in the sun. I need to examine my body monthly for any lesions that may be suspicious

B. I need to avoid sun exposure before 10am to 4pm

A nurse in a clinic is preparing to obtain a skin specimen from a client who has a suspected herpes infection. Which of the following actions should the nurse take? Select all that apply A. Scrape the site with a wooden tongue depressor B. Puncture the crusted area with a sterile needle C. Swab the crusted area with a sterile cotton-tipped applicator D. Place cotton tipped applicator in culturette tube E. Place culturette tube in ice

B. Puncture the crusted area with a sterile needle D. Place cotton tipped applicator in culturette tube E. Place culturette tube in ice

The nurse inspects the skin of a client who is suspected of having psoriasis. Which finding should the nurse note is this disorder is present? A. Oily skin B. Silvery-white scaly lesions C. Patchy hair loss and round, red macules with scales D. The presence of wheal patches scattered about the trunk

B. Silvery-white scaly lesions

A nurse caring for a client who has contact dermatitis and a new prescription for diphenhydramine. For which of the following adverse effects should the nurse monitor? A. Elevated blood glucose levels B. Urinary retention C. Hyperpigmentation of the skin D. Insomnia

B. Urinary retention

The nurse is assisting with caring for a client who is receiving intravenous fluids and who has sustained full thickness burn injuries of the back and legs. The nurse understands that which would provide the most reliable indicator for determining the adequacy of the fluid resuscitation? A. Vital signs B. Urine output C. Mental status D. Peripheral pulses

B. Urine output

Nurse employed in a long term care facility, is planning the clinical assignment for the day. The nurse knows not to assign which staff member to the client with a diagnosis of herpes zoster? A. A staff member who has never had roseola B. A staff member who has never had mumps C. An unlicensed assistive personnel who has never had chicken pox D. An unlicensed assistive personnel who has never had german measles

C. An unlicensed assistive personnel who has never had chicken pox

A nurse is reinforcing discharge instructions with a client who had skin biopsy with sutures. Which of the following client statements indicates that the teaching has been effective? A. I can expect redness around the site for 5 to 7 days B. I will most likely have a fever for the first few days C. I should apply an antibiotic ointment to the area D. I will make a return appointment in 3 days for removal of my sutures

C. I should apply an antibiotic ointment to the area

A nurse is reinforcing teaching with a client about a new prescription for clotrimazole topical cream. Which of the following statements should the nurse include in teaching? A. It reduces the discomfort of a herpetic infection but does not cure the infection B. This is a cream to treat a bacterial infection. C. I will apply the topical medication for up to 2 weeks after the lesions are gone. D. I will apply the cream to lesions while they are moist

C. I will apply the topical medication for up to 2 weeks after the lesions are gone.

A nurse is caring for a client who has sustained burns over 35%of his total body surface area. Most of the burns are full-thickness burns on the arms, face, neck, and shoulders. The clients voice has become hoarse. He has a brassy cough and is drooling. These findings are indications of which of the following? A. Pulmonary edema B. Bacterial pneumonia C. Inhalation injury D. Carbon monoxide poisoning

C. Inhalation injury

A nurse is assisting with the care of a client who sustained deep partial thickness and full thickness burns over 60% of his body 24hr ago and is requesting pain medication. The nurse should ensure the medication is administered using which of the following routes to administer the medication? A. Subcutaneous B. Oral C. Intravenous D. Transdermal

C. Intravenous

The nurse is caring for a client who has been admitted to the nursing unit after receiving flame burns to the face and chest. The nurse notes a hoarse cough, and the client is expectorating sputum with black flecks. The client suddenly becomes restless and his color is becoming dusky. Based on this data, which interpretation should the nurse make? A. The client is hypotensive B. Pain is present from the burn injury C. The burn has probably caused laryngeal edema, which has occluded the airway D. The client is afraid and is having a panic attack as a result of the unfamiliar surroundings

C. The burn has probably caused laryngeal edema, which has occluded the airway

The nurse is told that the assigned client is suspected of having methicillin-resistant staphylococcus aureas (MRSA). Which precautions should the nurse institute during the care of the client? A. Wear gloves only B. Wear mask and gloves C. Wear gown and gloves D. Avoid touching the clients clothes

C. Wear gown and gloves

A client arrives at the emergency department and has experienced frostbite to the right hand. What should the nurse expect to find when inspecting the clients hand? A. A pink, edematous hand B. Fiery red skin with edema in the nail beds C. Black fingertips surrounded by an erythematous rash D. A white color of the skin which is insensitive to the touch

D. A white color of the skin which is insensitive to the touch

The nurse is caring for a client with circumferential burns of both legs. Which leg position is appropriate for this type of burn? A. A dependent position B. Elevation of the knees C. Flat, without elevation D. Elevation above the level of the heart

D. Elevation above the level of the heart

The the health education nurse provides instructions to a group of clients regarding measures that will assist in preventing skin cancer. Which instruction should the nurse provide? Select all that apply. a. Sunscreen should be applied every eight hours. b. Use sunscreen when participating in outdoor activities. c. Wear a hat, opaque clothing, and sunglasses when in the sun. d. Avoid sun exposure in the late afternoon and early evening hours. e. Examine your body monthly for any lesions that may be suspicious.

b. Use sunscreen when participating in outdoor activities. c. Wear a hat, opaque clothing, and sunglasses when in the sun. e. Examine your body monthly for any lesions that may be suspicious. Rationale: the client should be instructed to avoid sun exposure between the hours of brightest sunlight: 10 a.m. and 4 p.m. Sunscreen, a hat, opaque clothing, and sunglasses should be warm for outdoor activities. The client should be instructed to examine the body monthly for appearances of any cancerous or pre-cancerous lesions. Sunscreen should be reapplied every 2 to 3 hours and after swimming or sweating; otherwise, the duration of protection is reduced.

A client with severe acne is seen in the clinic and the healthcare provider prescribes isotretinoin. the nurse reviews the clients medication record and would contact the health care provider if the client is also taking which medication? a. Digoxin b. Phenytoin c. Vitamin A d. Furosemide

c. Vitamin A Rationale: isotretinoin is a metabolite of vitamin A and can produce generalized intensification of isotretinoin toxicity. Because of the potential for increased toxicity, vitamin A supplements should be discontinued before isotretinoin therapy. There are no contraindications associated with digoxin, phenytoin, or Furosemide.