ATI Dermatological Practice Questions

A nurse is caring for a client who has a large wound healing by secondary intention. The nurse should inform the client that which of the following nutrients (in addition to protein) promotes wound healing? A. Vitamin B1 B. Calcium C. Vitamin C D. Potassium

Correct Answer: C. Vitamin C A diet high in protein and vitamin C is recommended because these nutrients promote wound healing. Incorrect Answers:A. Vitamin B1 promotes the functioning of the nervous system; however, it does not specifically promote wound healing. B. Calcium aids blood clotting and muscle contraction; however, it does not specifically promote wound healing. D. Potassium is necessary for muscle activity and fluid balance; however, it does not specifically promote wound healing.

A nurse is caring for a client who has burn injuries on his trunk. The nurse is explaining what to expect from the prescribed hydrotherapy. Which of the following statements by the client indicates an understanding of the teaching? A. "I will be on a special shower table." B. "The water temperature will be very cool to ease my pain." C. "The nurse will use a firm-bristled brush to remove loose skin." D. "The nurse will use scissors to open small blisters."

Correct Answer: A. "I will be on a special shower table." The special shower table facilitates examination and debridement of the wound during hydrotherapy. An advantage of using the showering technique as opposed to a tub bath is that the water can be kept at a constant temperature; there is also a lower risk of wound infection. Incorrect Answers:B. The nurse should use warm water during the hydrotherapy treatment to help the client maintain adequate body temperature. C. The nurse should use soft washcloths or gauze to scrub and debride the wounds gently. D. The nurse should leave small blisters intact but open large blisters.

A nurse is caring for an adolescent client who has burn wounds on her face and hands. Which of the following statements by the client indicates that she has adapted to her changed body image? A. "May I go with my family to the visitor's lounge?" B. "I'll see my friends when I get home." C. "My dad is coming to visit. Can you fix my hair for me?" D. "I told my cousins I'm in protective isolation."

Correct Answer: A. "May I go with my family to the visitor's lounge?" This statement demonstrates a positive self-image since the client is asking to visit with her family in a public setting. Incorrect Answers:B. This statement indicates that the client does not feel comfortable being seen by her peer group. Since peer interaction is important to an adolescent, the client's statement shows that she has not accepted the alterations in her face and hands. C. Asking for assistance with her appearance indicates the client has not yet accepted or adapted to her changed body image. Encouraging the client's participation in self-care activities is a suggested nursing intervention because the independence fosters self-worth and a positive self-image. D. This statement indicates that the client does not feel comfortable being seen by her extended family. It demonstrates an attempt to escape from interpersonal contact and indicates that the client has not accepted the alterations in her face and hands.

A nurse is teaching a client who has extensive deep partial- and full-thickness burns and requires a topical antimicrobial medication. The goal of this medication therapy is to reduce which of the following outcomes? A. Bacterial growth B. Scarring C. Skin graft size D. Pain

Correct Answer: A. Bacterial growth Topical antimicrobial medications (particularly broad-spectrum antimicrobials) help prevent bacteria from entering the body when a client has an impairment of the protective covering of the skin, as with burns. It and the dressing create a protective barrier between bacteria and the exposed body tissues. This therapy helps prevent infection. Incorrect Answers:B. Topical antimicrobials do not prevent scarring or minimize permanent damage to the integumentary system. C. Topical antimicrobials do not reduce the size of the skin grafts the client requires. D. Opioids, not topical antimicrobials, reduce pain.

A nurse in the emergency department is caring for a client who has a snakebite on her arm. Which of the following interventions should the nurse implement? A. Immobilize the limb at the level of the heart B. Apply a tourniquet to the affected limb C. Use a sterile scapula to incise the wound D. Apply ice to the skin over the snakebite wound

Correct Answer: A. Immobilize the limb at the level of the heart The emergency management of a client who has a snakebite focuses on limiting the spread of venom. Any constrictive clothing or jewelry should be removed before swelling worsens, and the affected limb should be immobilized at the level of the heart. Incorrect Answers:B. Although the use of tourniquets was recommended in the past for the emergency management of snakebites, this is no longer an accepted treatment and is now contraindicated. C. Although incising the wound was recommended in the past for the emergency management of snakebites, this is no longer an accepted treatment and is now contraindicated. D. Although the use of ice was recommended in the past for the emergency management of snakebites, this is no longer an accepted treatment and is now contraindicated.

A nurse is planning care for a client who has deep partial-thickness and full-thickness thermal burns over 40% of his total body surface and is in the acute phase of burn injury. Which of the following interventions should the nurse include in the plan? A. Initiate range-of-motion exercises B. Use clean technique to provide wound care C. Place the client on a low-protein diet D. Maintain the client on bed rest

Correct Answer: A. Initiate range-of-motion exercises The nurse should begin performing active and passive range-of-motion exercises with the client to maintain mobility and prevent contractures. Incorrect Answers:B. The nurse should use sterile technique to provide wound care for this client to reduce the risk of infection. C. The nurse should place the client on a high-protein, high-calorie diet to promote wound healing. D. The nurse should encourage the client to ambulate frequently to promote mobility and improve ventilation.

A nurse in a provider's office is assessing a client's skin lesions. The nurse notes that the lesions are 0.5 cm (0.20 in) in size, elevated, and solid with distinct borders. The nurse should document these findings as which of the following skin lesions? A. Papules B. Macules C. Wheals D. Vesicles

Correct Answer: A. Papules A papule is a small, solid, elevated lesion with distinct borders. It is usually smaller than 10 mm in diameter. Papules are common lesions of warts and elevated moles. Incorrect Answers:B. A macule is a change in the color of the skin that is flat, variably shaped, discolored, and small (typically <10 mm in diameter). Freckles and the rash associated with rubella are types of macules. C. Wheals (also known as hives) are transient, elevated, irregularly shaped lesions caused by localized edema. Wheals are a common manifestation of an allergic reaction. D. A vesicle is a circumscribed, elevated lesion or blister containing serous fluid. Vesicles typically arise in herpes simplex, poison ivy, and chickenpox.

A nurse is providing discharge instructions to a client who is postoperative following surgical excision of a basal cell carcinoma. Which of the following findings should the nurse include as an indication of a mole's potential malignancy? A. Ulceration B. Blanching of surrounding skin C. Dimpling D. Fading of color

Correct Answer: A. Ulceration Ulceration, bleeding, and exudation are indications of a mole's potential malignancy. Increasing size is also a warning sign. The nurse should emphasize the importance of lifetime follow-up evaluations and the proper techniques for self-examination of the skin every month. Incorrect Answers:B. Redness or swelling of the skin around a mole is an indication of potential malignancy. C. Dimpling is not an indication of a mole's potential malignancy. D. Darkening of a mole is associated with potential malignancy.

A nurse in a provider's office is caring for a client who has a new diagnosis of herpes zoster. The nurse should anticipate a prescription for which of the following medications? A. Zoster vaccine B. Acyclovir C. Amoxicillin D. Infliximab

Correct Answer: B. Acyclovir The nurse should anticipate a prescription for acyclovir, an antiviral medication that inhibits replication of the virus that causes herpes zoster. Incorrect Answers:A. The nurse should anticipate a prescription for the zoster vaccine for an older adult client to prevent herpes zoster. C. The nurse should anticipate a prescription for amoxicillin for a client who has a bacterial infection. D. The nurse should anticipate a prescription for infliximab for a client who has Crohn's disease.

A nurse in an emergency department is assessing a client who has extensive burns, including on her face. Which of the following assessments should the nurse perform first? A. Estimation of burn injury B. Characteristics of the cough and sputum C. Extent of peripheral edema D. Amount of urine output

Correct Answer: B. Characteristics of the cough and sputum The nurse should apply the ABC priority-setting framework, which emphasizes the basic core of human functioning: having an open airway, being able to breathe in adequate amounts of oxygen, and circulating oxygen to the body's organs via the blood. An alteration in any of these areas can indicate a threat to life and is the nurse's priority concern. When applying the ABC priority-setting framework, airway is always the highest priority because the airway must be clear for oxygen exchange to occur. Breathing is the second-highest priority because adequate ventilatory effort is essential in order for oxygen exchange to occur. Circulation is the third-highest priority because the delivery of oxygen to critical organs only occurs if the heart and blood vessels are capable of efficiently carrying oxygen to them. Therefore, the nurse's priority assessment is the client's cough characteristics. A client who has burns to the face is at risk for pulmonary injury, and the development of a brassy cough can indicate an impending loss of airway. Incorrect Answers:A. The nurse should determine the percentage of the client's total body surface area that is burned to ensure proper care and provide an estimation of prognosis; however, there is another assessment that the nurse should perform first. C. The nurse should assess the extent of the client's edema to determine the effects of the injury on the client's cardiovascular status; however, there is another assessment that the nurse should perform first. D. The nurse should accurately monitor the client's urine output to assess kidney function; however, there is another assessment that the nurse should perform first.

A nurse is teaching a group of clients about skin cancer. The nurse should explain that basal cell carcinoma originates from which of the following tissues? A. Subcutaneous B. Epidermis C. Dermis D. Stratum corneum

Correct Answer: B. Epidermis Basal cell carcinoma originates from the epidermal layer of the skin. It is the most common form of skin cancer. Incorrect Answers:A. Angiomas, not basal cell carcinomas, are an example of lesions that involve the skin and subcutaneous tissue. C. The dermis connects the epidermis to the subcutaneous tissue. Melanoma, not basal cell carcinoma, arises from this skin layer. D. The stratum corneum layer is the outermost or topmost layer of skin and is composed primarily of dead or peeling skin cells. Basal cell carcinoma does not arise from dead skin cells.

A nurse is caring for a client who has a prescription for silver sulfadiazine cream to be applied to her burn wounds. The nurse should evaluate the client for which of the following laboratory findings? A. Hyponatremia B. Leukopenia C. Hyperchloremia D. Elevated BUN

Correct Answer: B. Leukopenia Transient leukopenia is an adverse effect of silver sulfadiazine. Incorrect Answers:A. Silver sulfadiazine does not cause an electrolyte imbalance. C. Hyperchloremia and other electrolyte imbalances can be adverse effects of mafenide acetate solution or cream. D. Impaired kidney function is an adverse effect of gentamicin.

A community health nurse is teaching a group of clients about malignant melanoma. Which of the following traits places a client at risk for developing malignant melanoma? A. Brown eyes B. Light skin C. Black hair D. Dark skin

Correct Answer: B. Light skin Explanation: Light skin and less pigmentation place a client at risk for developing malignant melanoma. (A) Brown eyes do not place a client at risk for developing malignant melanoma. (C) Black hair does not place a client at risk for developing malignant melanoma. Clients who have red or blonde hair are at risk for developing malignant melanoma. (D) Dark skin does not place a client at risk for developing malignant melanoma

A nurse is caring for a client who has a lesion on the back of his right hand. The client asks the nurse which type of skin cancer is the most serious. Which of the following responses by the nurse is appropriate? A. Basal cell carcinoma B. Melanoma C. Actinic keratosis D. Squamous cell carcinoma

Correct Answer: B. Melanoma Melanomas are malignant neoplasms with atypical melanocytes in the epidermis, the dermis, and sometimes the subcutaneous cells. It is the most lethal type of skin cancer, often causing metastases in the bone, liver, lungs, spleen, CNS, and lymph nodes. Incorrect Answers:A. Basal cell carcinomas are the most common type of skin cancer and rarely metastasize. They arise from the basal cell layer of the epidermis or the hair follicles and generally appear on sun-exposed areas of the body. C. Actinic keratoses are premalignant. They can evolve into squamous cell carcinomas; however, they are not the most lethal type of skin cancer. D. Squamous cell carcinomas arise from the epidermis and are potentially metastatic; however, they are not the most lethal type of skin cancer.

A nurse is caring for a client whose wounds are covered with a heterograft dressing. In response to the client's questions about the dressing, the nurse explains that it is obtained from which of the following sources? A. Cadaver skin B. Pig skin C. Amniotic membranes D. Beef collagen

Correct Answer: B. Pig skin Heterografts are obtained from an animal, usually a pig. Incorrect Answers:A. Homographs are obtained from cadaver skin. C. Human amniotic membranes are used to treat burns; however, they are not heterograft dressings. D. Artificial skin made from beef collagen is used to treat burns; however, it is not a heterograft dressing.

A nurse is evaluating the laboratory values of a client who is in the resuscitation phase following a major burn. Which of the following laboratory findings should the nurse expect? A. Hemoglobin 10 g/dL B. Sodium 132 mEq/L C. Albumin 3.6 g/dL D. Potassium 4.0 mEq/dL

Correct Answer: B. Sodium 132 mEq/L This laboratory finding is below the expected reference range. The nurse should anticipate a low sodium level because sodium is trapped in interstitial space. Incorrect Answers:A. This laboratory value is below the expected reference range. The nurse should anticipate an elevated hemoglobin level during the resuscitation phase due to the loss of fluid volume. C. This laboratory finding is within the expected reference range. The nurse should anticipate a low albumin level during the resuscitation phase. D. This laboratory finding is within the expected reference range. The nurse should anticipate an elevated potassium level during the resuscitation phase.

A nurse is teaching a group of young adult clients about health promotion techniques to reduce the risk of skin cancer. Which of the following instructions should the nurse include? A. Apply a broad-spectrum sunscreen 5 min before sun exposure B. Wear a sun visor instead of a hat when outside in the sun C. Avoid exposure to the midday sun D. Use a tanning booth instead of sunbathing outdoors

Correct Answer: C. Avoid exposure to the midday sun The nurse should instruct clients to avoid skin exposure to the sun, especially during the midday hours of 1000 to 1600 when the sun rays are the strongest. Incorrect Answers:A. The nurse should instruct clients to apply a broad-spectrum sunscreen 15 min prior to sun exposure. B. The nurse should instruct clients to wear a wide-brimmed hat for better protection from the sun than a sun visor. D. The nurse should instruct clients to avoid sunbathing, as well as tanning booths, sunlamps, and tanning pills.

A nurse in a dermatology clinic is using the ABCDE method while screening several skin lesions for skin cancer on a client. Which of the following findings should the nurse report to the provider? A. Symmetric shape B. Border regularity C. Color variation within a lesion D. Diameter >4 mm

Correct Answer: C. Color variation within a lesion The C in the ABCDE method of screening for skin cancer stands for color variation within a lesion. The E stands for evolving or changing in any feature of the lesion. Incorrect Answers:A. The A in the ABCDE method of screening for skin cancer stands for asymmetric shape. B. The B in the ABCDE method of screening for skin cancer stands for border irregularity. D. The D in the ABCDE method of screening for skin cancer stands for a diameter >6 mm.

A nurse is screening a client for skin cancer. When teaching the client about skin cancer risk, which of the following risk factors should the nurse include? A. Cigarette smoking B. Low-fiber diet C. Excessive exposure to ultraviolet light D. Human papillomavirus

Correct Answer: C. Excessive exposure to ultraviolet light Excessive exposure to ultraviolet light (e.g. from sunlight or tanning beds), occupational exposure to chemical carcinogens, and chronic skin irritation are risk factors for skin cancer. Incorrect Answers:A. Cigarette smoking is a risk factor for lung cancer, not skin cancer. B. A low-fiber diet is a risk factor for colorectal cancer, not skin cancer. D. The human papillomavirus is a risk factor for cervical cancer, not skin cancer.

A nurse is caring for a client who has full-thickness burns covering 63% of her body and smoke inhalation. Which of the following nursing actions is the top priority? A. Monitor intake and output. B. Administer antibiotics. C. Monitor respiratory status. D. Encourage fluid and food intake.

Correct Answer: C. Monitor respiratory status. The priority action for the nurse when using the airway, breathing, and circulation (ABC) approach to client care is to monitor the client's respiratory status closely. Smoke inhalation most likely includes a thermal injury to the tracheobronchial tree. Edema from the inflammatory response to heat can obstruct the airway. Endotracheal intubation may become necessary to maintain a patent airway. Incorrect Answers: A. The nurse should monitor the client's intake and output because clients who have sustained major burns quickly dehydrate as a result of the fluid shift from the vascular system into the interstitial space; however, another action is the priority. B. Infection is a serious risk for clients who have sustained major burns, and antibiotic therapy is probable; however, another action is the priority. D. Nutritional support is essential for clients who have sustained major burns, although they might receive nutrients via IV or an enteral tube initially; another action is the priority.

A nurse on a surgical unit is caring for 4 clients who have healing wounds. Which of the following wounds should the nurse expect to heal by primary intention? A. Partial-thickness burn B. Stage III pressure ulcer C. Surgical incision D. Dehisced sternal wound

Correct Answer: C. Surgical incision With primary intention, a clean wound is closed mechanically, leaving well-approximated edges and minimal scarring. A surgical incision is an example of a wound that heals by primary intention. Incorrect Answers:A. A partial-thickness burn heals by spontaneous re-epithelialization. Since it involves the uppermost layers of the dermis, scarring can be minimal or extensive depending on the depth of the burn. B. A stage III pressure ulcer will heal by secondary intention. D. A dehisced sternal wound can either close by secondary or tertiary intention.

A nurse is assessing the abdominal incision of a client who is 3 days postoperative. The incision is slightly edematous and pink with crusting on the edges and is draining serosanguineous fluid. Which of the following assessments describes the incision? A. The incision is showing early signs of infection. B. The incision is showing early signs of dehiscence. C. The incision is showing signs of healing without complications. D. The incision is showing signs of developing a fistula.

Correct Answer: C. The incision is showing signs of healing without complications. These assessment findings are consistent with appropriate healing without complications. Incorrect Answers:A. Signs of wound infection include warmth, erythema, and purulent drainage. B. Dehiscence is the separation of the layers of skin and tissue in a wound. Signs of dehiscence include the client's report of something moving apart, increased wound drainage, and a visually apparent separation. D. A fistula is a complication of wound healing that involves the formation of an abnormal passageway within or from a wound. A common sign of fistula development is chronic drainage of fluids from the wound.

A nurse is assessing the skin of a client who has frostbite. The client has small blisters that contain blood, and the skin of the affected area does not blanch. The nurse should classify this injury as which of the following? A. First-degree frostbite B. Second-degree frostbite C. Third-degree frostbite D. Fourth-degree frostbite

Correct Answer: C. Third-degree frostbite When a client has third-degree frostbite, the skin of the affected area has small blisters that are blood-filled, and the skin does not blanch. Incorrect Answers:A. When a client has first-degree frostbite, the skin of the affected area is reddened and looks waxy. B. When a client has second-degree frostbite, the skin of the affected area has large, fluid-filled blisters. D. When a client has fourth-degree frostbite, the skin of the affected area is frozen. Blisters do not appear, and the client's muscles and bones are affected.

A nurse is providing teaching to a client who is wheelchair-bound and his caregiver about ways to reduce the risk of pressure ulcer formation. Which of the following instructions should the nurse include? A. "Move between the bed and the wheelchair once every 2 hr." B. "Make sure that your caregiver massages your skin daily." C. "Use a rubber ring when sitting on the bedside." D. "Shift your weight in the wheelchair every 15 min."

Correct Answer: D. "Shift your weight in the wheelchair every 15 min." This response addresses the safety issue of pressure ulcer risk. Pressure ulcers are most likely to develop if the client does not shift position frequently to relieve pressure. Incorrect Answers:A. The nurse should instruct wheelchair-bound clients who are at risk for pressure ulcer formation to change position at least once every hour. B. The nurse should instruct the client and his caregiver to avoid massaging the skin, especially over bony prominences, as this can further traumatize fragile tissues. C. The nurse should instruct the client and his caregiver to avoid using a rubber ring for sitting because it reduces circulation to the client's skin.

A nurse is caring for a client who has regular occupational exposure to sunlight and presents for evaluation of several skin lesions. Which of the following findings should alert the nurse to the possibility of malignant melanoma? A. A pearly papule that is 0.5 cm (0.20 in) wide with raised, indistinct borders on the upper right shoulder B. Several flat, pigmented, circumscribed areas of various sizes over the bridge of the nose C. A raised, circumscribed lesion on the face that contains yellow-white purulent material D. An irregularly shaped brown lesion with light blue areas on the neck

Correct Answer: D. An irregularly shaped brown lesion with light blue areas on the neck Malignant melanoma (the leading cause of death from skin cancer) is a neoplasm of dermal or epidermal cells. Exposure to sunlight increases the risk of this condition, and fair-skinned people have the highest risk. Malignant melanoma commonly starts in exposed skin areas like the back, scalp, face, and neck and metastasizes readily to other areas. Manifestations include a change in the color, size, or shape of a skin lesion with irregular borders in hues of blue, white, and red tones. Incorrect Answers:A. This describes basal cell carcinoma, a slow-growing skin tumor that results from sun exposure in clients who have fair skin. Basal cell carcinomas are usually pale in color and either pearly or flaky in appearance. B. This describes macules such as freckles. C. This describes a pustule such as acne lesions.

A nurse is assessing a client who is bedridden and was admitted from home. The nurse notes a shallow crater in the epidermis of the client's sacral area. The nurse should document that the client has a pressure ulcer at which of the following stages? A. IV B. I C. III D. II

Correct Answer: D. II A stage II pressure ulcer involves partial-thickness skin loss of the epidermis and the dermis. The ulcer is visible and superficial and can look like an abrasion, blister, or shallow crater. Edema persists, and the ulcer might become infected. The client might report pain, and there might be a small amount of drainage. Incorrect Answers:A. With a stage IV pressure ulcer, the client has full-thickness tissue loss, in addition to destruction, tissue necrosis, and visible damage to muscle, bone, or supporting structures. Sinus tracts, deep pockets of infection, tunneling, and undermining can occur. B. With a stage I pressure ulcer, the skin is intact with an area of persistent, nonblanchable redness, usually over a bony prominence that might feel warm or cool when touched. The tissue is swollen and congested, and the client might report discomfort at the site. With darker skin tones, the ulcer can appear blue or purple and different from other skin areas. C. A stage III pressure ulcer involves full-thickness tissue loss with damage to or necrosis of subcutaneous tissue. The ulcer might extend down to but not through the underlying fascia. The ulcer looks like a deep crater with or without undermining of adjacent tissue and without exposed muscle or bone. Drainage and infection are common.

A community health nurse is teaching a group of clients about melanoma. Which of the following characteristics of lesions associated with melanoma should the nurse include in the teaching? A. One solid color B. Symmetrical shape C. <6 mm in diameter D. Irregular border

Correct Answer: D. Irregular border The nurse should identify that skin cancer lesions, including melanoma, are expected to exhibit border irregularity. The nurse should instruct clients on the use of the ABCDE pneumonic when monitoring skin lesions: asymmetry of shape, border irregularity, color variation within one lesion, diameter of >6 mm, and evolution of any feature. Incorrect Answers:A. Skin cancer lesions, including melanoma, are expected to exhibit color variation. B. Skin cancer lesions, including melanoma, are expected to exhibit asymmetry in shape. C. Skin cancer lesions, including melanoma, are expected to exhibit a diameter that is >6 mm.

A nurse is assessing a client who has a lesion on his skin. Which of the following findings is a clinical manifestation of malignant melanoma? A. Rough, dry, scaly lesion B. Firm nodule with crusting C. Pearly papule with ulcerated center D. Irregularly shaped lesion with blue tones

Correct Answer: D. Irregularly shaped lesion with blue tones Malignant melanomas are irregularly shaped and can be blue, red, or white in tone. They often occur on the client's upper back and lower legs. Incorrect Answers:A. This finding is a clinical manifestation of actinic keratosis. B. This finding is a clinical manifestation of squamous cell carcinoma. C. This finding is a clinical manifestation of basal cell carcinoma.

A nurse is planning care for a client who has been admitted for the treatment of a malignant melanoma of the upper leg without metastasis. The nurse should plan to prepare the client for which of the following procedures? A. Curettage B. External radiation therapy C. Regional chemotherapy D. Surgical excision

Correct Answer: D. Surgical excision The therapeutic approach to malignant melanoma depends on the level of invasion and the depth of the lesion. Surgical excision is the treatment of choice for small, superficial lesions. Deeper lesions require wide local excision, followed by skin grafting. Incorrect Answers:A. Curettage is used for small lesions that are not melanomas. B. Melanoma is resistant to radiation therapy. However, radiation along with corticosteroids might be helpful to clients who have metastatic disease. C. Regional or topical chemotherapy is the treatment of choice for localized tumors and superficial basal cell carcinomas but not for malignant melanoma, which has an extremely high incidence of metastasis.

A nurse is assessing a client who sustained superficial partial-thickness and deep partial-thickness burns 72 hr ago. Which of the following findings should the nurse report to the provider? A. Edema in the burned extremities B. Severe pain at the burn sites C. Urine output of 30 mL/hr D. Temperature of 39.1°C (102.4°F)

Correct Answer: D. Temperature of 39.1°C (102.4°F) An elevated temperature is an indication of infection, and the nurse should report this finding to the provider. Sepsis is a critical finding following a major burn injury. Initially, burn wounds are relatively pathogen-free. On approximately the third day following the injury, early colonization of the wound surface by gram-negative organisms changes to predominantly gram-positive opportunistic organisms. Incorrect Answers:A. Significant edema is expected when fluid shifts after a burn injury. B. Superficial partial-thickness and deep partial-thickness burns are painful throughout burn therapy. C. A urinary output of 30 mL/hr is within the expected reference range. A decrease in urine output is expected with edema and fluid shifts around the fourth day following a major burn injury.

A nurse is conducting discharge teaching about foot care for a client who has diabetes mellitus. Which of the following instructions should the nurse include? A. Wear nylon socks with shoes every day B. Trim toenails by rounding the edges of the nail C. Apply lotion between the toes after bathing D. Test water temperature with the wrist

Correct Answer: D. Test water temperature with the wrist The nurse should instruct the client to test water temperature with the wrist or a thermometer to detect if the water is too hot or too cold. Clients with diabetes have peripheral nerve damage, making temperature determinations difficult and increasing the risk of burns. Incorrect Answers:A. The client should wear a clean pair of cotton socks every day with shoes. Cotton socks allow the client's feet to breathe and prevent moisture from collecting. B. The client should trim the toenails straight across and not round the edges of the toenail. This can create an ingrown toenail, causing pain and possible infection. C. The client should apply lotion to the feet after bathing, except for between the toes. This can create a moist area for bacteria to grow, increasing the risk of infection. Applying lotion between the toes can also cause skin breakdown and create an ulcer.