Integumentary

A client arrives at the emergency department after being rescued from a burning building. Both arms and the entire chest are covered with dry, leathery, charred skin that does not blanch. What is the priority for the client's care? 1. Administration of IV lactated Ringer's 2. Antibiotic administration 3. Incision through the burned tissue (escharotomy) 4. IV administration of analgesics

1

Four clients with different skin alterations come to the emergency department. Which client should the nurse advise that the health care provider (HCP) see first? 1. 8-year-old client who uses corticosteroid inhaler and has white patches on the tongue 2. 50-year-old client who developed a smooth, red, pinpoint rash after taking sulfa 3. 60-year-old client with pain and crusted blisters along the back 4. 70-year-old client who has erythema with a small pustule at the hair follicle

2

The nurse is conducting an educational community outreach program on melanoma screening. Which statement by a resident would indicate the need for further education? 1. Abrupt changes in the size or color of a mole are warning signs. 2. All new growths and pigmentations must be biopsied to rule out cancer. 3. Melanoma can occur as any color. 4. Melanoma does not always occur as a new mole.

2

When caring for a client with severe burns, the nurse can expect to administer pain medication via which route? 1. Intramuscular 2. Intravenous 3. Oral 4. Subcutaneous

2

A client who suffered a burn injury has received fluid resuscitation and is now diuresing, indicating the end of the emergency phase. Which prescription is the highest priorityat this time? 1. Administer enteral feedings at the return of bowel sounds 2. Assist the client in activities of daily living as tolerated 3. Contact the client's religious advisor for spiritual support 4. Educate the client's family about dressings and medications

1

The nurse is providing discharge teaching for a client who suffered full-thickness burns. Which statement by the client demonstrates a need for further instruction on the rehabilitation phase of a burn injury? 1. "I should avoid using lotion to prevent infection." 2. "I should perform range-of-motion exercises daily." 3. "I will avoid direct sun exposure for at least 3 months." 4. "I will wear pressure garments to minimize scars."

1

An adult client was severely burned in a warehouse accident. The client has second-degree burns on the right leg and right arm as well as the back. Using the rule of nines, the nurse estimates the percentage of the client's burns as which of these options? 1. 25% 2. 32% 3. 45% 4. 50%

3

A parent calls the nursing triage line during the evening. The parent says that a 7-year-old was found playing in an area with poison ivy and asks what to do. Which is the mostimportant instruction to give the parent? 1. Apply cool, wet compresses for itching 2. Apply topical cortisone ointment to the area 3. Discourage the child from scratching the area 4. Wash the skin where the contact occurred

4

The nurse is caring for a client in the intensive care unit who suffered partial-thickness burns to 36% of the body. During the first 24 hours, the nurse would anticipate which of the following assessments? 1. Hemoglobin 10.2 g/dL (102 g/L) 2. Hyperactive bowel sounds 3. Serum sodium 152 mEq/L (152 mmol/L) 4. Tall, peaked T waves on ECG

4

The nurse is caring for an adult client who was hospitalized after a car accident with third-degree burns over 50% of the body. Which solution can the nurse anticipate using for fluid resuscitation? 1. 0.45% normal saline 2. 5% dextrose normal saline 3. 5% dextrose in water 4. Lactated Ringer's

4

The unlicensed assistive personnel (UAP) reports finding a reddened area on a client's sacrum during a bath. What is the nurse's priority action? 1. Direct the UAP to apply a protective foam dressing 2. Document results of the Braden Scale in the electronic record 3. Notify the health care provider (HCP) 4. Perform an assessment on the client's skin

4

A nurse is caring for a client admitted to the intensive care unit for severe Stevens-Johnson syndrome (toxic epidermal necrolysis). Which interventions should be included in this client's care plan? Select all that apply. 1. Administer prescribed eye lubricants on schedule 2. Apply warm compresses gently to denuded skin 3. Implement reverse isolation precautions 4. Leave blankets off of client to avoid contaminating wounds 5. Provide massage as needed to relieve pain

1,2,3

A nurse is making a presentation on skin cancer prevention with special focus on melanoma at a community health forum. Which statements should the nurse include? Select all that apply. 1. Apply a broad-spectrum sunscreen, minimum SPF 15, before and during outdoor sports 2. Apply sunscreen immediately before participating in outdoor activities 3. Reapply sunscreen after swimming even if using waterproof sunscreen earlier 4. Serious sunburns can still occur on cloudy, overcast days 5. Use of tanning beds for 15 minutes or less will provide a base tan less likely to burn

1,3,4

An obese client with diabetes who had a bowel resection 5 days ago says, "I felt like I split open when I was coughing." On assessment, the nurse notes that the incision edges are separated and a loop of bowel is protruding through the wound. Which nursing actions would be appropriate? Select all that apply. 1. Administer one oral tablet of oxycodone prescribed PRN for pain 2. Assess a full set of vital signs 3. Cover the viscera with sterile dressings saturated in normal saline (NS) solution 4. Notify the health care provider (HCP) immediately 5. Place the client in low Fowler's position with knees slightly flexed

2,3,4,5

The nurse assesses a client with partial- and full-thickness thermal burns involving all posterior skin surfaces below the neck. Using the rule of nines, calculate the percentage of total body surface area affected. Record your answer using a whole number. Answer: %

45