NCLEX 10000 INTEGUMENTARY

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?

Patency of airway

While in a skilled nursing facility, a client contracts scabies, which is diagnosed the day after discharge. The client is living at her daughter's home with six other people. During her visit to the clinic, the client asks a staff nurse, "What should my family do?" The most accurate response from the nurse is:

"All family members need to be treated."

A client has suffered a deep partial-thickness burn to the right arm from a high-voltage source of energy that was not turned off while working on it. What is the priority nursing intervention in the acute phase of care?

A cardiac monitor should be used for at least 24 hours to anticipate the potential for cardiac dysrhythmias.

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 urine output consistently above 40 ml/hour (40 mL/hour)

A client's burn wounds are being cleaned twice a day in a hydrotherapy tub. Which intervention should be included in the plan of care before a hydrotherapy treatment is initiated?

Administer pain medication 30 minutes before therapy to help manage pain.

An occupational nurse is called to treat an employee who experienced a finger injury on a piece of equipment. When the nurse arrives, it is discovered that the finger tip was cut off at the first digit and is bleeding profusely. What should be the nurse's first action?

Apply direct pressure to the finger with a clean, dry cloth.

A nurse is providing education in a community setting about general measures to avoid excessive sun exposure. Which recommendation is appropriate?

Apply sunscreen with a sun protection factor (SPF) of 30 or more before sun exposure.

The nurse is caring for an immune compromised client with a fungal infection of the scalp. What recommendation should the nurse make to prevent future problems?

Avoid sharing combs and brushes.

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?

Beau's line

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?

Document her findings.

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?

Fear related to potential diagnosis of malignant melanoma.

A client has partial-thickness burns on both lower extremities and portions of the trunk. Which I.V. fluid does the nurse plan to administer first?

Lactated Ringer's solution

A nurse is developing a care plan for a client recovering from a serious thermal burn. What does the nurse determine is the priority goal of therapy?

Maintaining the client's fluid and electrolyte balance

The nurse is bathing a client and discovers a pressure ulcer on the buttocks (see photo). Which nursing intervention, following completion of the bath, is completed first?

Position the client off of the ulcer.

Which instruction is the most important to give a client who has recently had a skin graft?

Protect the graft from direct sunlight.

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.

Reposition the client every 2 hours. Perform range-of-motion exercises. Encourage the client to eat a well-balanced diet.

A nurse is caring for a client who has limited mobility and requires a wheelchair. The nurse has concern for circulation problems when which device is used?

Ring or donut

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?

Stage II pressure ulcer

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?

Tattoos are easily removed with laser surgery.

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?

The client's complete blood count readings reflect a reduced hematocrit.

Which statement would be appropriate for a nurse documenting a stage 1 pressure ulcer found on a client who is immobilized?

The client's skin is intact with non-blanchable redness of a localized area over a bony prominence.

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.

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.

A client has been admitted with severe burns. Lactated Ringer's has been ordered to infuse via a pump. Why is this solution being used?

To prevent signs of hypovolemic shock and restore circulation

A client with right sided hemiparesis has limited mobility. Which action should the nurse include in the plan of care to help maintain skin integrity?

Turn him regularly.

After teaching the parent of a child with severe burns about the importance of specific nutritional support in burn management, which selection of foods, if chosen by the parent from the child's diet menu, indicate the need for further instruction?

bacon, lettuce, and tomato sandwich; milk; and celery and carrot sticks

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:

call the health care provider (HCP) to report the loss of the radial pulse.

A nurse visits the employee health department because of mild itching and a rash on both hands. During the assessment interview, the employee health nurse should focus on:

chemical and latex glove use.

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?

chicken and orange slices

The physician orders "acyclovir, 200 mg P.O., every 4 hours while awake" for a client with herpes zoster. The nurse should inform the client that this drug may cause:

diarrhea.

A client with deep partial-thickness and full-thickness burns on the arms receives autografts. Two days later, the nurse finds the client doing arm exercises. The nurse provides additional client teaching because these exercises may:

dislodge the autografts.

A child has been prescribed diphenhydramine hydrochloride to help control the itching from atopic dermatitis. The nurse should instruct the parents to report which conditions? Select all that apply.

drowsiness thickened bronchial secretions upset stomach

A 17-year-old female with severe nodular acne is considering treatment with isotretinoin. Prior to beginning the medication, the nurse explains that the client will be required to:

enroll in a risk management plan.

The client with a major burn injury receives total parenteral nutrition (TPN). The expected outcome is to:

ensure adequate caloric and protein intake.

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?

exposure to moisture

While caring for the client with a burn injury who is experiencing hypersecretion of gastric acid, the nurse should observe the client for:

gastrointestinal ulceration.

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

melanoma.

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?

mobility status

The nurse assesses the client's burned right arm and notes increasing edema, absence of a radial pulse, and decreased sensation in the fingers. The nurse should:

notify the health care provider immediately.

After the initial phase of the burn injury, the client's plan of care will focus primarily on:

preventing infection.

When educating unlicensed nursing personnel (UAP) about how to prevent the development of pressure ulcers, the nurse should emphasize that most tissue injuries related to shearing can be prevented by:

proper positioning and moving of the client.

A nurse is assessing an immobile client and notes an area of sacral skin is reddened, but not broken. The reddened area continues to blanch and refill with fingertip pressure. The most appropriate nursing action at this time is to:

reposition the client off the reddened skin and reassess in a few hours.

Which action would be most helpful in preventing pressure ulcer formation in an at-risk client?

repositioning every hour

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:

some melanomas have a familial component and she should seek medical advice.

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?

supine

Which client is at greatest risk for inadequate nutrition?

the client with burns to 45% of the body

A nurse is caring for a client with severe burns and receiving fluid resuscitation. Which finding indicates that the client is responding to the fluid resuscitation?

urine output of 30 mL/h

The nurse is applying a hand mitt restraint for a client with pruritus (see figure). The nurse should first:

verify the prescription to use the restraint.

A client reports a firm, red nodule with a scaly crust on his back. Which of the following is the best nursing intervention?

Notify the healthcare provider.

Which disciplines should be consulted when caring for a client with a stage III heel ulcer?

Nutrition support and orthotics

The nurse is discharging an older adult to home after hospitalization for cellulitis of the right foot. The client originally scraped the foot on a rock while walking barefoot outside; the scrape became infected and eventually required hospitalization for wound care and several days of IV antibiotics. After reviewing discharge instructions, what statement by the client indicates the need for further teaching by the nurse?

"I will take the antibiotics until the redness goes away and my foot feels better."

A client in a semiprivate room is diagnosed with pediculosis corpus. A nurse will initiate treatment after moving the client to another room. The client's roommate asks the nurse for information about the client. What should the nurse say?

"I'm sorry, but I can't share confidential information."

A client reports to a physician's office for intradermal allergy testing. Before testing, the nurse provides client teaching. Which client statement indicates a need for further education?

"If I notice tingling in my lips or mouth, gargling may help the symptoms."

The nurse is caring for a teenage client on a burn unit who has sustained third-degree burns over 40% of the body. A family member asks why the client isn't reporting of more pain. Which of the following is the best response by the nurse?

"The severe burns have damaged nerves that sense pain."

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?

27%

A triage nurse in the emergency department admits a male client with second-degree burns on the anterior and posterior portions of both legs. Based on the Rule of Nines, what percentage of the body is burned? Record your answer using a whole number.

36

A nurse is evaluating a stage II pressure ulcer on a client. Which wound assessment findings should prompt the nurse to request a referral from the wound care nurse?

A wound measuring 2 cm × 2 cm × 0.5 cm with tan leathery appearan

A nurse is examining a client's scalp for evidence of lice. The nurse should pay particular attention to which part of the scalp?

Behind the ears

The nurse is aware that, in addition to the rule of nines, which is the most important assessment priority when assessing a client with facial burns?

Checking for airway patency

The nurse is providing an education seminar on skin care to clients and home care families. When discussing interventions, which areas have provided effective outcomes in preventing pressure ulcers? Select all that apply.

Clean the skin with warm water and a mild cleaning agent, then apply a moisturizer. Turn and reposition the client every 1 to 2 hours unless contraindicated. Use positioning devices to position the client and increase comfort.

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?

Contact

A client arrives at the emergency department after falling in the home. The nurse performing the assessment notes the presence of pediculosis corpus. The client's skin and clothing are dirty. The client reports that his children work and no one has time to assist him with his self-care activities. The nurse should:

Contact the nursing supervis

A nurse is caring for a client with a postoperative wound evisceration. Which action should the nurse perform first?

Cover the protruding internal organs with sterile gauze, moistened with sterile saline solution.

The nurse is planning care for an older adult with a pressure ulcer (see figure). What should the nurse do? Select all that apply.

Cover with protective dressing. Reposition the client every 2 hours. Request an alternating-pressure mattress.

A client with a severe staphylococcal infection is receiving the aminoglycoside gentamicin sulfate by the I.V. route. The nurse should assess the client for which adverse reaction?

Ototoxicity

A nurse has noticed an increase in the development of pressure ulcers on the nursing unit. Given the seriousness of the matter, what should the nurse do first?

Formally report her concerns to the nurse-manager.

When assessing a client with partial-thickness burns over 60% of the body, which finding should the nurse report immediately?

Hoarseness of the voice

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:

IV rate increase

The priority nursing diagnosis for a client who has just been admitted to the hospital with burns would be which of the following?

Impaired skin integrity

After sustaining a stroke, a client is transferred to the rehabilitation unit. The medical-surgical nurse reviews the client's residual neurological deficits with the rehabilitation nurse. Which neurological deficit places the client at the greatest risk for skin breakdown?

Incontinence and right-sided hemiparesis

When planning care for a client with burns on the upper torso, which nursing diagnosis should take the highest priority?

Ineffective airway clearance related to edema of the respiratory passages

A client presents with blistering wounds caused by an unknown chemical agent. How should the nurse intervene?

Irrigate the wounds with water.

A night-shift nurse receives a call from the emergency department about a client with herpes zoster who is going to be admitted to the floor. Based on this diagnosis, where should the nurse assign the client?

Private room

The nurse is developing a program on skin cancer prevention for a community group. Which information should be included in the program? Select all that apply.

Purchase sunscreen containing benzophenones to block UVA and UVB rays. Use sunscreen with a minimum of 30 sun protection factor (SPF).

A nurse formulates a nursing diagnosis of Impaired physical mobility for a client with full-thickness burns on the lower portions of both legs. To complete the nursing diagnosis statement, the nurse should add which "related-to" phrase?

Related to circumferential eschar

A client with atopic dermatitis is ordered a potent topical corticosteroid to be covered with an occlusive dressing. To address a potential client problem associated with this treatment, the nurse formulates the nursing diagnosis of Risk for injury. To complete the nursing diagnosis statement, the nurse should add which "related-to" phrase?

Related to percutaneous absorption of the topical corticosteroid

"I will take the antibiotics until the redness goes away and my foot feels better."

Replace lost fluids.

What is the primary goal of nursing care during the emergent phase after a burn injury?

Replace lost fluids.

A registered nurse (RN) is working with the licensed practical nurse (LPN) to care for a group of clients in a nursing home. How should the RN expect the LPN to communicate changes in the clients' wound status?

The RN communicates daily with the LPN about the condition of each resident.

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?

Urine output of 20 ml/hour

A nurse is preparing a discharge teaching plan for a client with atopic dermatitis. Which instruction should the nurse include in her teaching plan?

Use a topical skin moisturizer daily.

The registered nurse (RN) is referred to a client's home when a husband and wife have been confirmed to have scabies. The family asks, "How will we get rid of this?" When instructing on the proper procedure to wash contaminated clothing and sheets, which nursing instruction is a priority?

Use hot water throughout wash cycle.

A client from a nursing home arrives at an acute care facility for treatment related to complications of chronic obstructive pulmonary disease. A nurse performing the admission assessment notes the presence of a large stage III pressure ulcer. The client's daughter asks if the hospital can "treat the sore." What is the best initial response the nurse should state?

We will collaborate with the physician to obtain an order for the wound care nurse to see the client."

Four clients are assigned to a nurse. The nurse understands that the client with which condition would most benefit from ordered hyperbaric oxygen therapy?

a compromised skin graft.

A client visits the physician's office for treatment of a skin disorder. As a primary treatment, the nurse expects the physician to order:

a topical agent.

At about one-half hour before the daily whirlpool bath and dressing change the nurse should:

administer an analgesic.

Prevention of skin breakdown and maintenance of skin integrity among older clients is important because they are at greater risk secondary to:

altered protective pressure sensation.

The nurse is assessing a client with a burn injury using the "rule of nines" to determine:

amount of body surface area burned.

Which factor is most important for the nurse to consider when determining the angle at which to insert the needle for a subcutaneous injection?

amount of subcutaneous tissue

A client is being treated for severe pediculosis. The nurse should instruct the client to treat the problem in the eyebrows and eyelashes by:

applying petroleum jelly to lashes and brows three to four times a day.

When planning for risk management for clients who are at risk for development of pressure ulcers, the nurse should first:

identify at-risk clients on admission to the health care facility

In the acute phase of burn injury, which pain medication would most likely be given to the client to decrease the perception of the pain?

intravenous opioids

The nurse is assessing a client with dark skin for presence of a stage I pressure ulcer. The nurse should:

look for skin color that is darker than the surrounding tissue.

When bandaging the burned client's hand, the nurse should make certain that

the hand and finger surfaces do not touch.

An explosion at a chemical plant produces flames and smoke. More than 20 persons have burn injuries. Which victims should be transported to a burn center? Select all that apply.

the victim with chemical spills on both arms the victim with third-degree burns of both legs the victim in respiratory distress the victim who inhaled smoke

Which clients with burns will most likely require an endotracheal or tracheostomy tube? A client who has:

thermal burns to the head, face, and airway resulting in hypoxia.

During the first 48 to 72 hours of fluid resuscitation therapy after a major burn injury, the nurse should monitor hourly which information that will be used to determine the IV infusion rate?

urine output