Skin

483 KEY: Infection control| Standard Precautions| Transmission-Based Precautions MSC: Integrated Process: Nursing Process: Planning NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control SHORT ANSWER 1. An emergency room nurse cares for a client admitted with a 50% burn injury at 10:00 this morning. The client weighs 90 kg. Using the Parkland formula, calculate the rate at which the nurse should infuse intravenous fluid resuscitation when started at noon. (Record your answer using a whole number.) _____ mL/hr

1500 mL/hr The Parkland formula is 4 mL/kg/% total body surface area burn. This client needs 18,000 mL of fluid during the first 24 hours postburn. Half of the calculated fluid replacement needs to be administered during the first 8 hours after injury, and half during the next 16 hours. This client was burned at 10:00 AM, and fluid was not started until noon. Therefore, 9000 mL must be infused over the next 6 hours at a rate of 1500 mL/hr to meet the criteria of receiving half the calculated dose during the first 8 postburn hours. DIF: Applying/Application

N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for Alterations in Body Systems) MSC: Integrated Process: Nursing Process (Analysis) SHORT ANSWER 1. A client who weighs 90 kg and had a 50% burn injury at 10 AM arrives at the hospital at noon. Using the Parkland formula, calculate the rate that the nurse should use to deliver fluid when the IV is started at noon.

1500 mL/hr The Parkland formula is 4 mL/kg/%total body surface area (TBSA) burn. This client needs 18,000 mL of fluid during the first 24 hours post burn. Half of the calculated fluid replacement needs to be administered during the first 8 hours after injury, and half during the next 16 hours. This client was burned at 10 AM, and fluid was not started until noon. Therefore, 9000 mL must be infused over the next 6 hours at a rate of 1500 mL/hr to meet the criteria of receiving half the calculated dose during the first 8 post burn hours. DIF: Cognitive Level: Application/Applying or higher

460 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 2. The nurse estimates the extent of a burn using the rule of nines for a patient who has been admitted with deep partial-thickness burns of the anterior trunk and the entire left arm. What percentage of the patients total body surface area (TBSA) has been injured?

27% When using the rule of nines, the anterior trunk is considered to cover 18% of the patients body and each arm is 9%. DIF: Cognitive Level: Understand (comprehension)

478 KEY: Medication calculation MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 2. An emergency room nurse implements fluid replacement for a client with severe burn injuries. The provider prescribes a liter of 0.9% normal saline to infuse over 1 hour and 30 minutes via gravity tubing with a drip factor of 30 drops/mL. At what rate should the nurse administer the infusion? (Record your answer using a whole number and rounding to the nearest drop.) ____ drops/min

333 drops/min 1000 mL divided by 90 minutes, then multiplied by 30 drops, equals 333 drops/min. DIF: Applying/Application

470-471 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity SHORT ANSWER 1. An 80-kg patient with burns over 30% of total body surface area (TBSA) is admitted to the burn unit. Using the Parkland formula of 4 mL/kg/%TBSA, what is the IV infusion rate (mL/hour) for lactated Ringers solution that the nurse will administer during the first 8 hours?

600 mL The Parkland formula states that patients should receive 4 mL/kg/%TBSA burned during the first 24 hours. Half of the total volume is given in the first 8 hours and then the last half is given over 16 hours: 4 80 30 = 9600 mL total volume; 9600/2 = 4800 mL in the first 8 hours; 4800 mL/8 hr = 600 mL/hr. DIF: Cognitive Level: Apply (application)

458 | 464-465 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 18. A patient arrives in the emergency department with facial and chest burns caused by a house fire. Which action should the nurse take first? a. Auscultate the patients lung sounds. b. Determine the extent and depth of the burns. c. Infuse the ordered lactated Ringers solution. d. Administer the ordered hydromorphone (Dilaudid).

A A patient with facial and chest burns is at risk for inhalation injury, and assessment of airway and breathing is the priority. The other actions will be completed after airway management is assured. DIF: Cognitive Level: Apply (application)

p. 460 TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationAlterations in Body Systems) MSC: Integrated Process: Nursing Process (Assessment) 15. The nurse reads in the chart that a client has a fine, macular rash on the lower extremities. The nurse inspects the clients skin, looking for lesions that can be described with which term? a. Flat b. Raised c. Rough d. Blood-filled

A A rash that is flat is described as macular. The other descriptions are not accurate. DIF: Cognitive Level: Knowledge/Remembering

428 TOP: Nursing Process: Implementation MSC: NCLEX: Health Promotion and Maintenance 2. Which information should the nurse include when teaching a patient who has just received a prescription for ciprofloxacin (Cipro) to treat a urinary tract infection? a. Use a sunscreen with a high SPF when exposed to the sun. b. Sun exposure may decrease the effectiveness of the medication. c. Photosensitivity may result in an artificial-looking tan appearance. d. Wear sunglasses to avoid eye damage while taking this medication.

A The patient should stay out of the sun. If that is not possible, teach them to wear sunscreen when taking medications that can cause photosensitivity. The other statements are not accurate. DIF: Cognitive Level: Apply (application)

452 OBJ: Special Questions: Multiple Patients TOP: Nursing Process: Assessment MSC: NCLEX: Safe and Effective Care Environment 22. Which patient is most appropriate for the burn unit charge nurse to assign to a registered nurse (RN) who has floated from the hospital medical unit? a. A 34-year-old patient who has a weight loss of 15% from admission and requires enteral feedings. b. A 67-year-old patient who has blebs under an autograft on the thigh and has an order for bleb aspiration c. A 46-year-old patient who has just come back to the unit after having a cultured epithelial autograft to the chest d. A 65-year-old patient who has twice-daily burn debridements and dressing changes to partial-thickness facial burns

A An RN from a medical unit would be familiar with malnutrition and with administration and evaluation of response to enteral feedings. The other patients require burn assessment and care that is more appropriate for staff who regularly care for burned patients. DIF: Cognitive Level: Analyze (analysis)

425 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 7. When performing a skin assessment, the nurse notes several angiomas on the chest of an older patient. Which action should the nurse take next? a. Assess the patient for evidence of liver disease. b. Discuss the adverse effects of sun exposure on the skin. c. Teach the patient about possible skin changes with aging. d. Suggest that the patient make an appointment with a dermatologist.

A Angiomas are a common occurrence as patients get older, but they may occur with systemic problems such as liver disease. The patient may want to see a dermatologist to have the angiomas removed, but this is not the initial action by the nurse. The nurse may need to teach the patient about the effects of aging on the skin and about the effects of sun exposure, but the initial action should be further assessment. DIF: Cognitive Level: Apply (application)

444 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity 24. The nurse working in the dermatology clinic assesses a young adult female patient who is taking isotretinoin (Accutane) to treat severe cystic acne. Which assessment finding is most indicative of a need for further questioning of the patient? a. The patient recently had an intrauterine device removed. b. The patient already has some acne scarring on her forehead. c. The patient has also used topical antibiotics to treat the acne. d. The patient has a strong family history of rheumatoid arthritis.

A Because isotretinoin is teratogenic, contraception is required for women who are using this medication. The nurse will need to determine whether the patient is using other birth control methods. More information about the other patient data may also be needed, but the other data do not indicate contraindications to isotretinoin use. DIF: Cognitive Level: Apply (application)

431 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 4. A patient in the dermatology clinic has a thin, scaly erythematous plaque on the right cheek. Which action should the nurse take? a. Prepare the patient for a biopsy. b. Teach about the use of corticosteroid creams. c. Explain how to apply tretinoin (Retin-A) to the face. d. Discuss the need for topical application of antibiotics.

A Because the appearance of the lesion suggests actinic keratosis or possible squamous cell carcinoma (SCC), the appropriate treatment would be excision and biopsy. Over-the-counter (OTC) corticosteroids, topical antibiotics, and Retin-A would not be used for this lesion. DIF: Cognitive Level: Apply (application)

419 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 2. Which integumentary assessment data from an older patient admitted with bacterial pneumonia is of most concern for the nurse? a. Reports a history of allergic rashes b. Scattered macular brown areas on extremities c. Skin brown and wrinkled, skin tenting on forearm d. Longitudinal nail bed ridges noted; sparse scalp hair

A Because the patient will be receiving antibiotics to treat the pneumonia, the nurse should be most concerned about her history of allergic rashes. The nurse needs to do further assessment of possible causes of the allergic rashes and whether she has ever had allergic reactions to any drugs, especially antibiotics. The assessment data in the other response would be normal for an older patient. DIF: Cognitive Level: Apply (application)

489 KEY: Psychosocial response| coping MSC: Integrated Process: Nursing Process: Evaluation NOT: Client Needs Category: Psychosocial Integrity 7. An emergency room nurse assesses a client who was rescued from a home fire. The client suddenly develops a loud, brassy cough. Which action should the nurse take first? a. Apply oxygen and continuous pulse oximetry. b. Provide small quantities of ice chips and sips of water. c. Request a prescription for an antitussive medication. d. Ask the respiratory therapist to provide humidified air.

A Brassy cough and wheezing are some of the signs seen with inhalation injury. The first action by the nurse is to give the client oxygen. Clients with possible inhalation injury also need continuous pulse oximetry. Ice chips and humidified room air will not help the problem, and antitussives are not warranted. DIF: Applying/Application

N/A TOP: Client Needs Category: Psychosocial Integrity (Grief and Loss) MSC: Integrated Process: Nursing Process (Evaluation) 10. A client is in the emergency department after being rescued from a house fire. After the initial assessment, the client develops a loud, brassy cough. What intervention by the nurse takes priority? a. Apply oxygen and continuous pulse oximetry. b. Allow the client to suck on small quantities of ice chips. c. Request an antitussive medication from the physician. d. Have the respiratory therapist provide humidified room air.

A Brassy cough and wheezing are some of the signs seen with inhalation injury. The first action by the nurse is to give the client oxygen. Clients with possible inhalation injury also need continuous pulse oximetry. Ice chips and humidified room air will not help the problem, and antitussives are not warranted. DIF: Cognitive Level: Application/Applying or higher

N/A TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral TherapiesExpected Actions/Outcomes) MSC: Integrated Process: Nursing Process (Implementation) 32. The nurse assesses a client in the burn unit after the client was repositioned by the nursing assistant. The nurse intervenes after finding the client repositioned in what manner? a. Supine with one pillow behind the head b. Semi-Fowlers position with arms elevated c. Wrists extended to 30 degrees in a splint d. A towel roll placed under the neck or shoulder

A Clients must be positioned to prevent contractures. The function that would be disrupted by a contracture to the posterior neck is flexion. The client should not be positioned with a pillow behind the head; this would increase flexion. The nurse must intervene and position the client so that neck flexion does not occur. The other options include proper positioning techniques that will help prevent contracture. DIF: Cognitive Level: Application/Applying or higher

N/A TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationIllness Management) MSC: Integrated Process: Nursing Process (Implementation) 26. Which nursing intervention is likely to be most helpful in providing adequate nutrition while a client is recovering from a thermal burn injury? a. Allowing the client to eat whenever he or she wants b. Beginning parenteral nutrition high in calories c. Including 3000 kcal/day of calories with meals d. Providing a low-protein, high-fat diet

A Clients should request food whenever they think they can eat, not just according to the hospitals standard meal schedule. The nurse needs to work with a dietitian to provide a high-calorie, high-protein diet to help with wound healing. Clients who can eat solid foods should ingest as many calories as possible; they may need as many as 5000 kcal/day. Specific caloric requirements can be determined by the dietitian. Parenteral nutrition may be given as a last resort because it is invasive and can lead to infectious and metabolic complications. DIF: Cognitive Level: Application/Applying or higher

N/A TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationIllness Management) MSC: Integrated Process: Nursing Process (Evaluation) 31. Which intervention by the nurse is most appropriate to reduce a clients pain after a burn injury? a. Administering morphine sulfate 4 mg intravenously b. Administering morphine sulfate 4 mg intramuscularly c. Applying ice to the burned area for 20 minutes d. Avoiding tactile stimulation near the burned area

A Drug therapy for pain management requires opioid and non-opioid analgesics. The IV route is used because of problems with absorption from the muscle and the stomach. Tactile stimulation can be used for pain management. For the client to avoid shivering, the room must be kept warm, and ice should not be used. Ice would decrease blood flow to the area. DIF: Cognitive Level: Application/Applying or higher

486 KEY: Medication| antibiotic MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 15. A nurse cares for a client with burn injuries. Which intervention should the nurse implement to appropriately reduce the clients pain? a. Administer the prescribed intravenous morphine sulfate. b. Apply ice to skin around the burn wound for 20 minutes. c. Administer prescribed intramuscular ketorolac (Toradol). d. Decrease tactile stimulation near the burn injuries.

A Drug therapy for pain management requires opioid and nonopioid analgesics. The IV route is used because of problems with absorption from the muscle and the stomach. For the client to avoid shivering, the room must be kept warm, and ice should not be used. Ice would decrease blood flow to the area. Tactile stimulation can be used for pain management. DIF: Applying/Application

488 KEY: Psychosocial response| coping MSC: Integrated Process: Nursing Process: Evaluation NOT: Client Needs Category: Psychosocial Integrity 6. The nurse assesses a client who has a severe burn injury. Which statement indicates the client understands the psychosocial impact of a severe burn injury? a. It is normal to feel some depression. b. I will go back to work immediately. c. I will not feel anger about my situation. d. Once I get home, things will be normal.

A During the recovery period, and for some time after discharge from the hospital, clients with severe burn injuries are likely to have psychological problems that require intervention. Depression is one of these problems. Grief, loss, anxiety, anger, fear, and guilt are all normal feelings that can occur. Clients need to know that problems of physical care and psychological stresses may be overwhelming. DIF: Applying/Application

N/A TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationIllness Management) MSC: Integrated Process: Nursing Process (Evaluation) 9. Which finding indicates to the nurse that a client understands the psychosocial impact of a severe burn injury? a. It is normal to feel some depression. b. I will go back to work immediately. c. I will not feel anger about my situation. d. Once I get home, things will be normal.

A During the recovery period, and for some time after discharge from the hospital, clients with severe burn injuries are likely to have psychological problems that require intervention. Depression is one of these problems. Grief, loss, anxiety, anger, fear, and guilt are all normal feelings that can occur. Clients need to know that problems of physical care and psychological stresses may be overwhelming. DIF: Cognitive Level: Application/Applying or higher

460-461 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity 6. A patient has just been admitted with a 40% total body surface area (TBSA) burn injury. To maintain adequate nutrition, the nurse should plan to take which action? a. Insert a feeding tube and initiate enteral feedings. b. Infuse total parenteral nutrition via a central catheter. c. Encourage an oral intake of at least 5000 kcal per day. d. Administer multiple vitamins and minerals in the IV solution.

A Enteral feedings can usually be initiated during the emergent phase at low rates and increased over 24 to 48 hours to the goal rate. During the emergent phase, the patient will be unable to eat enough calories to meet nutritional needs and may have a paralytic ileus that prevents adequate nutrient absorption. Vitamins and minerals may be administered during the emergent phase, but these will not assist in meeting the patients caloric needs. Parenteral nutrition increases the infection risk, does not help preserve gastrointestinal function, and is not routinely used in burn patients. DIF: Cognitive Level: Apply (application)

N/A TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral TherapiesAdverse Effects/Contraindications/Side Effects/Interactions) MSC: Integrated Process: Nursing Process (Implementation) 30. The nurse has been teaching a client about skin grafting procedures. What statement indicates that the client needs further education about allografts? a. Because the graft is my own skin, there is no chance it wont take. b. For a few days after surgery, the donor sites will be painful. c. I will have some scarring in the area where the skin is removed. d. I am still at risk for infection after the procedure until the burn heals.

A Factors other than tissue type, such as circulation and infection, influence whether and how well a graft will work. The client should be prepared for the possibility that not all grafting procedures will be successful. Donor sites will be painful after surgery, scarring can occur in the area where skin is removed for grafting, and the client is still at risk for infection. DIF: Cognitive Level: Application/Applying or higher

454 KEY: Skin lesions/wounds| infection| Transmission-Based Precautions MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control 12. A nurse assesses a client who has a chronic wound. The client states, I do not clean the wound and change the dressing every day because it costs too much for supplies. How should the nurse respond? a. You can use tap water instead of sterile saline to clean your wound. b. If you dont clean the wound properly, you could end up in the hospital. c. Sterile procedure is necessary to keep this wound from getting infected. d. Good hand hygiene is the only thing that really matters with wound care.

A For chronic wounds in the home, clean tap water and nonsterile supplies are acceptable and serve as cheaper alternatives to sterile supplies. Of course, if the wound becomes grossly infected, the client may end up in the hospital, but this response does not provide any helpful information. Good handwashing is important, but it is not the only consideration. DIF: Understanding/Comprehension

N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for Alterations in Body Systems) MSC: Integrated Process: Nursing Process (Implementation) 29. The nurse uses topical gentamicin sulfate (Garamycin) on a clients burn injury. Which laboratory value does the nurse monitor? a. Creatinine b. Red blood cells c. Sodium d. Magnesium level

A Gentamicin is nephrotoxic, and sufficient amounts can be absorbed through burn wounds to affect kidney function. Any client receiving gentamicin by any route should have kidney function monitored. Topical gentamicin will not affect the red blood cell count or the sodium or magnesium level. DIF: Cognitive Level: Application/Applying or higher

466 KEY: Skin lesions/wounds| infection control MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 14. A nurse administers topical gentamicin sulfate (Garamycin) to a clients burn injury. Which laboratory value should the nurse monitor while the client is prescribed this therapy? a. Creatinine b. Red blood cells c. Sodium d. Magnesium

A Gentamicin is nephrotoxic, and sufficient amounts can be absorbed through burn wounds to affect kidney function. Any client receiving gentamicin by any route should have kidney function monitored. Topical gentamicin will not affect the red blood cell count or the sodium or magnesium levels. DIF: Applying/Application

479 KEY: Intravenous fluids| vascular perfusion MSC: Integrated Process: Nursing Process: Assessment NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 21. A nurse delegates hydrotherapy to an unlicensed assistive personnel (UAP). Which statement should the nurse include when delegating this activity? a. Keep the water temperature constant when showering the client. b. Assess the wound beds during the hydrotherapy treatment. c. Apply a topical enzyme agent after bathing the client. d. Use sterile saline to irrigate and clean the clients wounds.

A Hydrotherapy is performed by showering the client on a special shower table. The UAP should keep the water temperature constant. This process allows the nurse to assess the wound beds, but a UAP cannot complete this act. Topical enzyme agents are not part of hydrotherapy. The irrigation does not need to be done with sterile saline. DIF: Applying/Application

N/A TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationMedical Emergencies) MSC: Integrated Process: Nursing Process (Implementation) 20. A client who is admitted after a thermal burn injury has the following vital signs: blood pressure, 70/40; heart rate, 140 beats/min; and respiratory rate, 25 breaths/min. He is pale, and it is difficult to find pedal pulses. Which action does the nurse take first? a. Begin intravenous fluid resuscitation. b. Check pulses with a Doppler device. c. Obtain a complete blood count (CBC). d. Obtain an electrocardiogram (ECG).

A Hypovolemic shock is a common cause of death in the emergent phase of clients with serious injury. Fluids can treat this problem. ECG and CBC will be taken to ascertain whether a cardiac or bleeding problem is causing these vital signs. However, these are not actions that the nurse would take immediately. Checking pulses would indicate perfusion to the periphery, but this is not an immediate nursing action. DIF: Cognitive Level: Application/Applying or higher

N/A TOP: Client Needs Category: Safe and Effective Care Environment (Management of CareEstablishing Priorities) MSC: Integrated Process: Nursing Process (Assessment) 17. The nurse observes hirsutism in a female client. What does the nurse do next? a. Assess for deepening of the voice. b. Assess personal hygiene habits. c. Document the finding. d. Prepare the client for a biopsy.

A Increased hair growth on the face and chest of a female client (hirsutism) is one manifestation of hormonal imbalance. The nurse looks for additional associated changes in fat distribution and capillary fragility (Cushings syndrome) or clitoral enlargement and deepening of the voice (possible ovarian dysfunction). The other options are not related to this condition. DIF: Cognitive Level: Application/Applying or higher

N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialLaboratory Values) MSC: Integrated Process: Nursing Process (Analysis) 18. Ten hours after a client with 50% burns is admitted, her blood glucose level is 152 mg/dL. What action by the nurse is most appropriate? a. Document the finding. b. Obtain a family history for diabetes. c. Repeat the glucose measurement. d. Stop IV fluids containing dextrose.

A Neural and hormonal compensation to the stress of the burn injury in the emergent phase increases liver glucose production and release. An acute rise in the blood glucose level is an expected client response and is helpful in the generation of energy needed for the increased metabolism that accompanies this trauma. A family history of diabetes could place her at higher risk for the disease, but this is not a priority at this time. The glucose level is not high enough to warrant retesting. The cause of her elevated blood glucose is not the IV fluid. DIF: Cognitive Level: Application/Applying or higher

p. 453 TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationPathophysiology) MSC: Integrated Process: Nursing Process (Assessment) 14. A client has two skin lesions, each the size of a nickel, on his chest. Both lesions are flat and are a darker color than the rest of the clients skin. How does the nurse document this finding? a. Two 2-cm hyperpigmented patches b. Two 1-inch erythematous plaques c. Two 2-mm pigmented papules d. Two 1-inch moles

A Patches are larger flat areas of the skin. The information provided does not indicate a mole or the presence of erythema. DIF: Cognitive Level: Comprehension/Understanding

458 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 25. The charge nurse observes the following actions being taken by a new nurse on the burn unit. Which action by the new nurse would require an intervention by the charge nurse? a. The new nurse uses clean latex gloves when applying antibacterial cream to a burn wound. b. The new nurse obtains burn cultures when the patient has a temperature of 95.2 F (35.1 C). c. The new nurse administers PRN fentanyl (Sublimaze) IV to a patient 5 minutes before a dressing change. d. The new nurse calls the health care provider for a possible insulin order when a nondiabetic patients serum glucose is elevated.

A Sterile gloves should be worn when applying medications or dressings to a burn. Hypothermia is an indicator of possible sepsis, and cultures are appropriate. Nondiabetic patients may require insulin because stress and high calorie intake may lead to temporary hyperglycemia. Fentanyl peaks 5 minutes after IV administration, and should be used just before and during dressing changes for pain management. DIF: Cognitive Level: Apply (application)

447 KEY: Skin lesions/wounds MSC: Integrated Process: Nursing Process: Planning NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care 9. A nurse who manages client placements prepares to place four clients on a medical-surgical unit. Which client should be placed in isolation awaiting possible diagnosis of infection with methicillin-resistant Staphylococcus aureus(MRSA)? a. Client admitted from a nursing home with furuncles and folliculitis b. Client with a leg cut and other trauma from a motorcycle crash c. Client with a rash noticed after participating in sporting events d. Client transferred from intensive care with an elevated white blood cell count

A The client in long-term care and other communal environments is at high risk for MRSA. The presence of furuncles and folliculitis is also an indication that MRSA may be present. A client with an open wound from a motorcycle crash would have the potential to develop MRSA, but no signs are visible at present. The rash following participation in a sporting event could be caused by several different things. A client with an elevated white blood cell count has the potential for infection but should be at lower risk for MRSA than the client admitted from the communal environment. DIF: Applying/Application

450 KEY: Skin lesions/wounds MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Health Promotion and Maintenance 11. A nurse assesses an older client who is scratching and rubbing white ridges on the skin between the fingers and on the wrists. Which action should the nurse take? a. Place the client in a single room. b. Administer an antihistamine. c. Assess the clients airway. d. Apply gloves to minimize friction.

A The clients presentation is most likely to be scabies, a contagious mite infestation. The client needs to be admitted to a single room and treated for the infestation. Secondary interventions may include medication to decrease the itching. This is not an allergic manifestation; therefore, antihistamine and airway assessments are not indicated. Gloves may decrease skin breakdown but would not address the clients infectious disorder. DIF: Applying/Application

N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialSystem-Specific Assessments) MSC: Integrated Process: Nursing Process (Assessment) 8. A client is admitted with inflamed soft tissue folds around his nail plates. Which question by the nurse elicits the most useful information about the possible condition? a. What do you do for a living? b. Do you keep your nails manicured? c. Do you have diabetes? d. Have you had any fungal nail infections?

A The condition, chronic paronychia, is common in people with frequent intermittent exposure to water, such as homemakers, bartenders, and laundry workers. DIF: Cognitive Level: Application/Applying or higher

462 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 9. A patient with circumferential burns of both legs develops a decrease in dorsalis pedis pulse strength and numbness in the toes. Which action should the nurse take? a. Notify the health care provider. b. Monitor the pulses every 2 hours. c. Elevate both legs above heart level with pillows. d. Encourage the patient to flex and extend the toes on both feet.

A The decrease in pulse in a patient with circumferential burns indicates decreased circulation to the legs and the need for an escharotomy. Monitoring the pulses is not an adequate response to the decrease in circulation. Elevating the legs or increasing toe movement will not improve the patients circulation. DIF: Cognitive Level: Apply (application)

438-439 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 25. There is one opening in the schedule at the dermatology clinic, and 4 patients are seeking appointments today. Which patient will the nurse schedule for the available opening? a. 38-year old with a 7-mm nevus on the face that has recently become darker b. 62-year-old with multiple small, soft, pedunculated papules in both axillary areas c. 42-year-old with complaints of itching after using topical fluorouracil on the nose d. 50-year-old with concerns about skin redness after having a chemical peel 3 days ago

A The description of the lesion is consistent with possible malignant melanoma. This patient should be assessed as soon as possible by the health care provider. Itching is common after using topical fluorouracil and redness is an expected finding a few days after a chemical peel. Skin tags are common, benign lesions after midlife. DIF: Cognitive Level: Analyze (analysis)

453 KEY: Medication| infection MSC: Integrated Process: Nursing Process: Analysis NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 18. A nurse prepares to discharge a client who has a wound and is prescribed home health care. Which information should the nurse include in the hand-off report to the home health nurse? a. Recent wound assessment, including size and appearance b. Insurance information for billing and coding purposes c. Complete health history and physical assessment findings d. Resources available to the client for wound care supplies

A The hospital nurse should provide details about the wound, including size and appearance and any special wound needs, in a hand-off report to the home health nurse. Insurance information is important to the home health agency and manager, but this is not appropriate during this hand-off report. The nurse should report focused assessment findings instead of a complete health history and physical assessment. The home health nurse should work with the client to identify community resources. DIF: Understanding/Comprehension

469 TOP: Nursing Process: Evaluation MSC: NCLEX: Psychosocial Integrity 13. The nurse caring for a patient admitted with burns over 30% of the body surface assesses that urine output has dramatically increased. Which action by the nurse would best ensure adequate kidney function? a. Continue to monitor the urine output. b. Monitor for increased white blood cells (WBCs). c. Assess that blisters and edema have subsided. d. Prepare the patient for discharge from the burn unit.

A The patients urine output indicates that the patient is entering the acute phase of the burn injury and moving on from the emergent stage. At the end of the emergent phase, capillary permeability normalizes and the patient begins to diurese large amounts of urine with a low specific gravity. Although this may occur at about 48 hours, it may be longer in some patients. Blisters and edema begin to resolve, but this process requires more time. White blood cells may increase or decrease, based on the patients immune status and any infectious processes. The WBC count does not indicate kidney function. The patient will likely remain in the burn unit during the acute stage of burn injury. DIF: Cognitive Level: Understand (comprehension)

N/A TOP: Client Needs Category: Psychosocial Integrity (Grief and Loss) MSC: Integrated Process: Teaching/Learning 6. The nurse has provided instruction on the facial pressure garment to a client with facial burns. Which statement indicates that the client understands these instructions? a. My scars should be less severe with the use of this mask. b. The mask will help protect my skin from sun damage. c. This treatment will help prevent infection. d. Using the mask will keep scars from being permanent.

A The purpose of wearing the pressure garment over burn injuries for up to 1 year is to prevent hypertrophic scarring and contractures from forming. Scars will still be present. Although the mask does provide protection of sensitive, newly healed skin and grafts from sun exposure, this is not the purpose of wearing the mask. The pressure garment will not alter the risk for infection. DIF: Cognitive Level: Application/Applying or higher

428 TOP: Nursing Process: Implementation MSC: NCLEX: Health Promotion and Maintenance 6. The health care provider diagnoses impetigo in a patient who has crusty vesicopustular lesions on the lower face. Which instructions should the nurse include in the teaching plan? a. Clean the infected areas with soap and water. b. Apply alcohol-based cleansers on the lesions. c. Avoid use of antibiotic ointments on the lesions. d. Use petroleum jelly (Vaseline) to soften crusty areas.

A The treatment for impetigo includes softening of the crusts with warm saline soaks and then soap-and-water removal. Alcohol-based cleansers and use of petroleum jelly are not recommended for impetigo. Antibiotic ointments, such as mupirocin (Bactroban), may be applied to the lesions. DIF: Cognitive Level: Apply (application)

441 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity 10. A patient with atopic dermatitis has been using a high-potency topical corticosteroid ointment for several weeks. The nurse should assess for which adverse effect? a. Thinning of the affected skin b. Alopecia of the affected areas c. Reddish-brown discoloration of the skin d. Dryness and scaling in the areas of treatment

A Thinning of the skin indicates that atrophy, a possible adverse effect of topical corticosteroids, is occurring. The health care provider should be notified so that the medication can be changed or tapered. Alopecia, red-brown discoloration, and dryness/scaling of the skin are not adverse effects of topical corticosteroid use. DIF: Cognitive Level: Apply (application)

478 KEY: Medication calculation MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 1. The nurse is planning care for an older client who has very thin skin on the backs of the hands and arms. What is the clients priority problem? a. Risk for injury b. Infection c. Poor self-image d. Discomfort

A Thinning skin, with decreased attachment between the dermis and the epidermis, is at increased risk for injury in response to even minimal trauma or shearing events. If injury occurred, infection would be a possible problem. Thin skin should not cause discomfort. Poor self-image does not take priority over the risk for injury. DIF: Cognitive Level: Application/Applying or higher

N/A TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationAlterations in Body Systems) MSC: Integrated Process: Nursing Process (Implementation) 1. The nurse is planning care for an older client who has very thin skin on the backs of the hands and arms. What is the clients priority problem? a. Risk for injury b. Infection c. Poor self-image d. Discomfort

A Thinning skin, with decreased attachment between the dermis and the epidermis, is at increased risk for injury in response to even minimal trauma or shearing events. If injury occurred, infection would be a possible problem. Thin skin should not cause discomfort. Poor self-image does not take priority over the risk for injury. DIF: Cognitive Level: Application/Applying or higher

439 KEY: Skin breakdown| Braden Scale| coping MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Psychosocial Integrity 21. A nurse assesses a client who has a lesion on the skin that is suspicious for skin cancer, as shown below: Which diagnostic test should the nurse anticipate being ordered for this client? a. Punch skin biopsy b. Viral cultures c. Woods lamp examination d. Diascopy

A This lesion is suspicious for skin cancer and a biopsy is needed. A viral culture would not be appropriate. A Woods lamp examination is used to determine if skin lesions have characteristic color changes. Diascopy eliminates erythema, making skin lesions easier to examine. DIF: Applying/Application

461 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 21. Which patient should the nurse assess first? a. A patient with smoke inhalation who has wheezes and altered mental status b. A patient with full-thickness leg burns who has a dressing change scheduled c. A patient with abdominal burns who is complaining of level 8 (0 to 10 scale) pain d. A patient with 40% total body surface area (TBSA) burns who is receiving IV fluids at 500 mL/hour

A This patient has evidence of lower airway injury and hypoxemia and should be assessed immediately to determine the need for oxygen or intubation. The other patients should also be assessed as rapidly as possible, but they do not have evidence of life-threatening complications. DIF: Cognitive Level: Apply (application)

440 KEY: Skin breakdown MSC: Integrated Process: Nursing Process: Evaluation NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control 4. A nurse cares for a client who has a deep wound that is being treated with a wet-to-damp dressing. Which intervention should the nurse include in this clients plan of care? a. Change the dressing every 6 hours. b. Assess the wound bed once a day. c. Change the dressing when it is saturated. d. Contact the provider when the dressing leaks.

A Wet-to-damp dressings are changed every 4 to 6 hours to provide maximum dbridement. The wound should be assessed each time the dressing is changed. Dry gauze dressings should be changed when the outer layer becomes saturated. Synthetic dressings can be left in place for extended periods of time but need to be changed if the seal breaks and the exudate leaks. DIF: Applying/Application

452 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 16. An employee spills industrial acids on both arms and legs at work. What is the priority action that the occupational health nurse at the facility should take? a. Remove nonadherent clothing and watch. b. Apply an alkaline solution to the affected area. c. Place cool compresses on the area of exposure. d. Cover the affected area with dry, sterile dressings.

A With chemical burns, the initial action is to remove the chemical from contact with the skin as quickly as possible. Remove nonadherent clothing, shoes, watches, jewelry, glasses, or contact lenses (if face was exposed). Flush chemical from wound and surrounding area with copious amounts of saline solution or water. Covering the affected area or placing cool compresses on the area will leave the chemical in contact with the skin. Application of an alkaline solution is not recommended. DIF: Cognitive Level: Apply (application)

428 KEY: Support| coping MSC: Integrated Process: Communication and Documentation NOT: Client Needs Category: Psychosocial Integrity 8. A nurse assesses a client who has open lesions. Which action should the nurse take first? a. Put on gloves. b. Ask the client about his or her occupation. c. Assess the clients pain. d. Obtain vital signs.

A Nurses should wear gloves as part of Standard Precautions when examining skin that is not intact. The other options should be completed after gloves are put on. DIF: Remembering/Knowledge

424 KEY: Skin breakdown| hygiene MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Health Promotion and Maintenance 5. A nurse assesses a client who has two skin lesions on his chest. Each lesion is the size of a nickel, flat, and darker in color than the clients skin. How should the nurse document these lesions? a. Two 2-cm hyperpigmented patches b. Two 1-inch erythematous plaques c. Two 2-mm pigmented papules d. Two 1-inch moles

A Patches are larger flat areas of the skin. The information provided does not indicate a mole or the presence of erythema. DIF: Applying/Application

422 KEY: Skin lesions/wounds| documentation MSC: Integrated Process: Communication and Documentation NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation 12. A nurse assesses an older adult client with the skin disorder shown below: How should the nurse document this finding? a. Petechiae b. Ecchymoses c. Actinic lentigo d. Senile angiomas

A Petechiae, or small, reddish purple nonraised lesions that do not fade or blanch with pressure, are pictured here. Ecchymoses are larger areas of hemorrhaging, commonly known as bruising. Actinic lentigo presents as paper-thin, transparent skin. Senile angiomas, also known as cherry angiomas, are red raised lesions. DIF: Remembering/Knowledge

422 KEY: Cyanosis MSC: Integrated Process: Nursing Process: Assessment NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 2. A nurse assesses a client who is admitted with inflamed soft-tissue folds around the nail plates. Which question should the nurse ask to elicit useful information about the possible condition? a. What do you do for a living? b. Are your nails professionally manicured? c. Do you have diabetes mellitus? d. Have you had a recent fungal infection?

A The condition chronic paronychia is common in people with frequent intermittent exposure to water, such as homemakers, bartenders, and laundry workers. The other questions would not provide information specifically related to this assessment finding. DIF: Applying/Application

429 KEY: Standard Precautions| skin lesions/wounds MSC: Integrated Process: Nursing Process: Assessment NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control 9. A nurse assesses a client who has a chronic skin disorder. Which finding indicates the client is effectively coping with the disorder? a. Clean hair and nails b. Poor eye contact c. Disheveled appearance d. Drapes a scarf over the face

A The nurse should complete a psychosocial assessment to determine if the client is coping effectively. Signs of adequate coping include clean hair, skin, and nails; good eye contact; and being socially active. A disheveled appearance and draping a scarf over the face to hide the clients appearance demonstrate that the client may be having difficulty coping with his or her condition. DIF: Understanding/Comprehension

N/A TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationIllness Management) MSC: Integrated Process: Nursing Process (Implementation) OTHER 1. A client is in the emergency department with a burn calculated to be 35% TBSA. The nurse prepares the client for an IV insertion in which location?

A [subclavian vein] Clients with burns greater than 25% TBSA are at great risk for hypovolemic shock and need fluid resuscitation. The large volume of fluids this client needs will be delivered at a very rapid rate, so the IV needs to be a central venous catheter instead of a peripheral IV. All other sites are peripheral sites. DIF: Cognitive Level: Application/Applying or higher

456 KEY: Skin lesions/wounds MSC: Integrated Process: Nursing Process: Assessment NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation 6. A nurse delegates care for a client who has open skin lesions. Which statements should the nurse include when delegating this clients hygiene care to an unlicensed assistive personnel (UAP)? (Select all that apply.) a. Wash your hands before touching the client. b. Wear gloves when bathing the client. c. Assess skin for breakdown during the bath. d. Apply lotion to lesions while the skin is wet. e. Use a damp cloth to scrub the lesions.

A, B All health care providers should follow Standard Precautions when caring for clients who have any open skin areas. This includes hand hygiene and wearing gloves when in contact with the lesions. The UAP is not qualified to assess the clients skin. The other statements are not appropriate for the care of open skin lesions. DIF: Applying/Application

447 KEY: Skin lesions/wounds| medications| anticoagulants MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control MULTIPLE RESPONSE 1. A nurse manages wound care for clients on a medical-surgical unit. Which client wounds are paired with the appropriate treatments? (Select all that apply.) a. Client with a left heel ulcer with slight necrosis Whirlpool treatments b. Client with an eschar-covered sacral ulcer Surgical dbridement c. Client with a sunburn and erythema Soaking in warm water for 20 minutes d. Client with urticaria Wet-to-dry dressing changes every 6 hours e. Client with a sacral ulcer with purulent drainage Transparent film dressing

A, B Necrotic tissue should be removed so that healing can take place. Whirlpool treatment can gently remove the necrosis. A wound covered with eschar most likely needs surgical dbridement. Warm water would not be recommended for a client with erythema. A wet-to-dry dressing and a transparent film dressing are not appropriate for urticaria or pressure ulcers, respectively. DIF: Applying/Application

420 KEY: Skin lesions/wounds| nutrition MSC: Integrated Process: Nursing Process: Assessment NOT: Client Needs Category: Physiological Integrity: Basic Care and Comfort 3. A nurse teaches a client to perform total skin self-examinations on a monthly basis. Which statements should the nurse include in this clients teaching? (Select all that apply.) a. Look for asymmetry of shape and irregular borders. b. Assess for color variation within each lesion. c. Examine the distribution of lesions over a section of the body. d. Monitor for edema or swelling of tissues. e. Focus your assessment on skin areas that itch.

A, B Clients should be taught to examine each lesion following the ABCDE features associated with skin cancer: asymmetry of shape, border irregularity, color variation within one lesion, diameter greater than 6 mm, and evolving or changing in any feature. DIF: Applying/Application

474 KEY: Infection control| Standard Precautions MSC: Integrated Process: Nursing Process: Analysis NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential MULTIPLE RESPONSE 1. A nurse cares for a client with burn injuries during the resuscitation phase. Which actions are priorities during this phase? (Select all that apply.) a. Administer analgesics. b. Prevent wound infections. c. Provide fluid replacement. d. Decrease core temperature. e. Initiate physical therapy.

A, B, C Nursing priorities during the resuscitation phase include securing the airway, supporting circulation and organ perfusion by fluid replacement, keeping the client comfortable with analgesics, preventing infection through careful wound care, maintaining body temperature, and providing emotional support. Physical therapy is inappropriate during the resuscitation phase but may be initiated after the client has been stabilized. DIF: Applying/Application

430-431 OBJ: Special Questions: Prioritization; Multiple Patients TOP: Nursing Process: Planning MSC: NCLEX: Safe and Effective Care Environment MULTIPLE RESPONSE 1. A nurse is teaching a patient with contact dermatitis of the arms and legs about ways to decrease pruritus. Which information should the nurse include in the teaching plan (select all that apply)? a. Cool, wet cloths or dressings can be used to reduce itching. b. Take cool or tepid baths several times daily to decrease itching. c. Add oil to your bath water to aid in moisturizing the affected skin. d. Rub yourself dry with a towel after bathing to prevent skin maceration. e. Use of an over-the-counter (OTC) antihistamine can reduce scratching.

A, B, E Cool or tepid baths, cool dressings, and OTC antihistamines all help reduce pruritus and scratching. Adding oil to bath water is not recommended because of the increased risk for falls. The patient should use the towel to pat (not rub) the skin dry. DIF: Cognitive Level: Analyze (analysis)

473 KEY: Skin lesions/wounds| pharmacologic pain management| infection control MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care 2. A nurse cares for a client with burn injuries who is experiencing anxiety and pain. Which nonpharmacologic comfort measures should the nurse implement? (Select all that apply.) a. Music as a distraction b. Tactile stimulation c. Massage to injury sites d. Cold compresses e. Increasing client control

A, B, E Nonpharmacologic comfort measures for clients with burn injuries include music therapy, tactile stimulation, massaging unburned areas, warm compresses, and increasing client control. DIF: Remembering/Knowledge

474 KEY: Older adult MSC: Integrated Process: Nursing Process: Analysis NOT: Client Needs Category: Health Promotion and Maintenance 5. A nurse plans care for a client with burn injuries. Which interventions should the nurse implement to prevent infection in the client? (Select all that apply.) a. Ask all family members and visitors to perform hand hygiene before touching the client. b. Carefully monitor burn wounds when providing each dressing change. c. Clean equipment with alcohol between uses with each client on the unit. d. Allow family members to only bring the client plants from the hospitals gift shop. e. Use aseptic technique and wear gloves when performing wound care.

A, B, E To prevent infection in a client with burn injuries the nurse should ensure everyone performs hand hygiene, monitor wounds for signs of infection, and use aseptic technique, including wearing gloves when performing wound care. The client should have disposable equipment that is not shared with another client, and plants should not be allowed in the clients room. DIF: Applying/Application

451 KEY: Skin lesions/wounds| infection| transmission precautions MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control 4. A nurse cares for older adult clients in a long-term acute care facility. Which interventions should the nurse implement to prevent skin breakdown in these clients? (Select all that apply.) a. Use a lift sheet when moving the client in bed. b. Avoid tape when applying dressings. c. Avoid whirlpool therapy. d. Use loose dressing on all wounds. e. Implement pressure-relieving devices.

A, B, E Using a lift sheet will prevent shearing forces from tearing skin. Tape should be avoided so that the skin wont tear. Using pressure-relieving devices for clients who are at risk for pressure ulcer formation, including older adults, is a proactive approach to prevent skin breakdown. No contraindication to using whirlpool therapy for the older client is known. Dressings should be applied as prescribed, not so loose that they do not provide required treatment, and not so tight that they decrease blood flow to tissues. DIF: Applying/Application

417 | 422 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity 2. Which activities can the nurse working in the outpatient clinic delegate to a licensed practical/vocational nurse (LPN/LVN) (select all that apply)? a. Administer patch testing to a patient with allergic dermatitis. b. Interview a new patient about chronic health problems and allergies. c. Apply a sterile dressing after the health care provider excises a mole. d. Teach a patient about site care after a punch biopsy of an upper arm lesion. e. Explain potassium hydroxide testing to a patient with a superficial skin infection.

A, C Skills such as administration of patch testing and sterile dressing technique are included in LPN/LVN education and scope of practice. Obtaining a health history and patient education require more critical thinking and registered nurse (RN) level education and scope of practice. DIF: Cognitive Level: Apply (application)

485 KEY: Nutrition| nutritional requirements MSC: Integrated Process: Nursing Process: Planning NOT: Client Needs Category: Physiological Integrity: Basic Care and Comfort 4. A nurse cares for an older client with burn injuries. Which age-related changes are paired appropriately with their complications from the burn injuries? (Select all that apply.) a. Slower healing time Increased risk for loss of function from contracture formation b. Reduced inflammatory response Deep partial-thickness wound with minimal exposure c. Reduced thoracic compliance Increased risk for atelectasis d. High incidence of cardiac impairments Increased risk for acute kidney injury e. Thinner skin May not exhibit a fever when infection is present

A, C, D Slower healing time will place the older adult client at risk for loss of function from contracture formation due to the length of time needed for the client to heal. A pre-existing cardiac impairment increases risk for acute kidney injury from decreased renal blood flow, and reduced thoracic compliance places the client at risk for atelectasis. Reduced inflammatory response places the client at risk for infection without a normal response, including fever. Clients with thinned skin are at greater risk for deeper wounds from minimal exposure. DIF: Remembering/Knowledge

421 KEY: Collaboration| skin lesions/wounds| older adult MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care 2. A nurse plans care for a client who has a wound that is not healing. Which focused assessments should the nurse complete to develop the clients plan of care? (Select all that apply.) a. Height b. Allergies c. Alcohol use d. Prealbumin laboratory results e. Liver enzyme laboratory results

A, C, D Nutritional status can have a significant impact on skin health and wound healing. The care plan for a client with poor nutritional status should include a high-protein, high-calorie diet. To determine the clients nutritional status, the nurse should assess height and weight, alcohol use, and prealbumin laboratory results. These data will provide information related to vitamin and protein deficiencies, and obesity. Allergies and liver enzyme laboratory results will not provide information about nutrition status or wound healing. DIF: Applying/Application

480 KEY: Nonpharmacologic pain management MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Physiological Integrity: Basic Care and Comfort 3. A nurse plans care for a client with burn injuries. Which interventions should the nurse include in this clients plan of care to ensure adequate nutrition? (Select all that apply.) a. Provide at least 5000 kcal/day. b. Start an oral diet on the first day. c. Administer a diet high in protein. d. Collaborate with a registered dietitian. e. Offer frequent high-calorie snacks.

A, C, D, E A client with a burn injury needs a high-calorie diet, including at least 5000 kcal/day and frequent high-calorie snacks. The nurse should collaborate with a registered dietitian to ensure the client receives a high-calorie and high-protein diet required for wound healing. Oral diet therapy should be delayed until GI motility resumes. DIF: Remembering/Knowledge

447 KEY: Skin lesions/wounds| delegation| hygiene| unlicensed assistive personnel (UAP) MSC: Integrated Process: Communication and Documentation NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care 7. A nurse cares for a client who reports pain related to eczematous dermatitis. Which nonpharmacologic comfort measures should the nurse implement? (Select all that apply.) a. Cool, moist compresses b. Topical corticosteroids c. Heating pad d. Tepid bath with cornstarch e. Back rub with baby oil

A, D For a client with eczematous dermatitis, the goal of comfort measures is to decrease inflammation and help dbride crusts and scales. The nurse should implement cool, moist compresses and tepid baths with additives such as cornstarch. Topical corticosteroids are a pharmacologic intervention. A heating pad and a back rub with baby oil are not appropriate for this client and could increase inflammation and discomfort. DIF: Applying/Application

447 KEY: Skin lesions/wounds MSC: Integrated Process: Nursing Process: Evaluation NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation 2. A nurse plans care for a client who is immobile. Which interventions should the nurse include in this clients plan of care to prevent pressure sores? (Select all that apply.) a. Place a small pillow between bony surfaces. b. Elevate the head of the bed to 45 degrees. c. Limit fluids and proteins in the diet. d. Use a lift sheet to assist with re-positioning. e. Re-position the client who is in a chair every 2 hours. f. Keep the clients heels off the bed surfaces. g. Use a rubber ring to decrease sacral pressure when up in the chair.

A, D, F A small pillow decreases the risk for pressure between bony prominences, a lift sheet decreases friction and shear, and heels have poor circulation and are at high risk for pressure sores, so they should be kept off hard surfaces. Head-of-the-bed elevation greater than 30 degrees increases pressure on pelvic soft tissues. Fluids and proteins are important for maintaining tissue integrity. Clients should be repositioned every hour while sitting in a chair. A rubber ring impairs capillary blood flow, increasing the risk for a pressure sore. DIF: Applying/Application

440 KEY: Skin lesions/wounds| nutrition| interdisciplinary team MSC: Integrated Process: Nursing Process: Analysis NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 23. A nurse evaluates the following data in a clients chart: Admission Note Prescriptions Wound Care 78-year-old male with a past medical history of atrial fibrillation is admitted with a chronic leg wound Warfarin sodium (Coumadin) Sotalol (Betapace) Vacuum-assisted wound closure (VAC) treatment to leg wound Based on this information, which action should the nurse take first? a. Assess the clients vital signs and initiate continuous telemetry monitoring. b. Contact the provider and express concerns related to the wound treatment prescribed. c. Consult the wound care nurse to apply the VAC device. d. Obtain a prescription for a low-fat, high-protein diet with vitamin supplements.

B A client on anticoagulants is not a candidate for VAC because of the incidence of bleeding complications. The health care provider needs this information quickly to plan other therapy for the clients wound. The nurse should contact the wound care nurse after alternative orders for wound care are prescribed. Vital signs and telemetry monitoring is appropriate for a client who has a history of atrial fibrillation and should be implemented as routine care for this client. A low-fat, high-protein diet with vitamin supplements will provide the client with necessary nutrients for wound healing but can be implemented after wound care, vital signs, and telemetry monitoring. DIF: Analyzing/Analysis

458 KEY: Skin lesions/wounds| patient-centered care MSC: Integrated Process: Caring NOT: Client Needs Category: Psychosocial Integrity 20. A nurse assesses a wife who is caring for her husband. She has a Braden Scale score of 9. Which question should the nurse include in this assessment? a. Do you have a bedpan at home? b. How are you coping with providing this care? c. What are you doing to prevent pediculosis? d. Are you sharing a bed with your husband?

B A client with a Braden Scale score of 9 is at high risk for skin breakdown and requires moderate to maximum assistance to prevent further breakdown. Family members who care for clients at home may experience a disruption in family routines and added stress. The nurse should assess the wifes feelings and provide support for coping with changes. Asking about the clients toileting practices, prevention of pediculosis, and sleeping arrangements do not provide information about the caregivers support and coping mechanisms and ability to continue to care for her husband. DIF: Applying/Application

N/A TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationMedical Emergencies) MSC: Integrated Process: Nursing Process (Analysis) 21. A client is brought to the emergency department by an emergency medical services (EMS) squad after being burned with unknown chemicals. The clients body is covered with a white, powdery substance, and the client cries out, Get this stuff off me! Its burning me! Which action by the nurse is most appropriate? a. Have the client take a shower, and bag all clothing. b. Brush the substance off the client and remove clothes. c. Call poison control to try to identify the chemical. d. Start an IV line and prepare to administer analgesics.

B A priority first action in burn care is to stop the burning process. Chemicals can continue to burn the client even after they have been removed, so removing them from the client is an important action. With unknown dry substances, adding water could potentiate their action, so the best action is to brush off as much of the chemical as possible from the client and clothing, then remove the clothing. Calling poison control would take too long if the chemical could be identified, and analgesics should be given after the burning process has been halted by removal of the offending substance. DIF: Cognitive Level: Application/Applying or higher

476 KEY: Skin lesions/wounds MSC: Integrated Process: Nursing Process: Assessment NOT: Client Needs Category: Health Promotion and Maintenance 20. A nurse assesses a client admitted with deep partial-thickness and full-thickness burns on the face, arms, and chest. Which assessment finding should alert the nurse to a potential complication? a. Partial pressure of arterial oxygen (PaO2) of 80 mm Hg b. Urine output of 20 mL/hr c. Productive cough with white pulmonary secretions d. Core temperature of 100.6 F (38 C)

B A significant loss of fluid occurs with burn injuries, and fluids must be replaced to maintain hemodynamics. If fluid replacement is not adequate, the client may become hypotensive and have decreased perfusion of organs, including the brain and kidneys. A low urine output is an indication of poor kidney perfusion. The other manifestations are not complications of burn injuries. DIF: Applying/Application

N/A TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection ControlStandard Precautions/Transmission-Based Precautions/Surgical Asepsis) MSC: Integrated Process: Nursing Process (Implementation) 2. When providing care for a client with an acute burn injury, which nursing intervention is most important to prevent infection by autocontamination? a. Avoid sharing equipment such as blood pressure cuffs between clients. b. Change gloves between wound care on different parts of the clients body. c. Use the closed method of burn wound management for all wound care. d. Use proper and consistent handwashing by all members of the staff.

B Autocontamination is the transfer of microorganisms from one area to another area of the same clients body, causing infection of a previously uninfected area. Although all techniques listed can help reduce the risk for infection, only changing gloves between carrying out wound care on different parts of the clients body can prevent autocontamination. DIF: Cognitive Level: Application/Applying or higher

466 KEY: Infection control| Standard Precautions| collaboration MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care 2. The nurse is caring for a client with an acute burn injury. Which action should the nurse take to prevent infection by autocontamination? a. Use a disposable blood pressure cuff to avoid sharing with other clients. b. Change gloves between wound care on different parts of the clients body. c. Use the closed method of burn wound management for all wound care. d. Advocate for proper and consistent handwashing by all members of the staff.

B Autocontamination is the transfer of microorganisms from one area to another area of the same clients body, causing infection of a previously uninfected area. Although all techniques listed can help reduce the risk for infection, only changing gloves between performing wound care on different parts of the clients body can prevent autocontamination. DIF: Applying/Application

N/A TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation-Medical Emergencies) MSC: Integrated Process: Nursing Process (Implementation) 1. A 38-year-old female patient states that she is using topical fluorouracil to treat actinic keratoses on her face. Which additional assessment information will be most important for the nurse to obtain? a. History of sun exposure by the patient b. Method of birth control used by the patient c. Length of time the patient has used fluorouracil d. Appearance of the treated areas on the patients face

B Because fluorouracil is teratogenic, it is essential that the patient use a reliable method of birth control. The other information is also important for the nurse to obtain, but lack of reliable birth control has the most potential for serious adverse medication effects. DIF: Cognitive Level: Apply (application)

461 OBJ: Special Questions: Delegation TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care Environment 26. Which nursing action is a priority for a patient who has suffered a burn injury while working on an electrical power line? a. Obtain the blood pressure. b. Stabilize the cervical spine. c. Assess for the contact points. d. Check alertness and orientation.

B Cervical spine injuries are commonly associated with electrical burns. Therefore stabilization of the cervical spine takes precedence after airway management. The other actions are also included in the emergent care after electrical burns, but the most important action is to avoid spinal cord injury. DIF: Cognitive Level: Apply (application)

449 KEY: Hand-off communication| skin lesions/wounds MSC: Integrated Process: Communication and Documentation NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care 19. A nurse assesses a client who has psoriasis. Which action should the nurse take first? a. Don gloves and an isolation gown. b. Shake the clients hand and introduce self. c. Assess for signs and symptoms of infections. d. Ask the client if she might be pregnant.

B Clients with psoriatic lesions are often self-conscious of their skin. The nurse should first provide direct contact and touch without gloves to establish a good report with the client. Psoriasis is not an infectious disease, nor is it contagious. The nurse would not need to wear gloves or an isolation gown. Obtaining a health history and assessing for an infection and pregnancy should be completed after establishing a report with the client. DIF: Applying/Application

N/A TOP: Client Needs Category: Health Promotion and Maintenance (Techniques of Physical Assessment) MSC: Integrated Process: Nursing Process (Assessment) 4. A client has a bluish tinge to the palms, soles, and conjunctivae. Based on these assessment data, what does the nurse do next? a. Take a medication history. b. Assess pulse oximetry. c. Assess the clients personal hygiene. d. Palpate the soles and palms.

B Cyanosis can be present when impaired gas exchange occurs. In a client with dark skin, cyanosis can be seen because the palms, soles, and conjunctivae have a bluish tinge. The nurse should assess for systemic oxygenation before continuing with other assessments. DIF: Cognitive Level: Application/Applying or higher

N/A TOP: Client Needs Category: Health Promotion and Maintenance (Lifestyle Choices) MSC: Integrated Process: Teaching/Learning 4. The nurse is conducting a home safety class. It is most important for the nurse to include which information in the teaching plan? a. Have an escape route everyone knows about. b. Keep a smoke detector in each bedroom. c. Use space heaters instead of gas heaters. d. Use carbon monoxide detectors in the garage.

B Everyone should use smoke detectors and carbon monoxide detectors in their home environment (just not in a garage). Recommendations are that each bedroom should have a separate smoke detector. Smoke detectors should also be placed in the hallway of each story, in the kitchen, in each stairwell, and by each entrance. Space heaters can be a cause of fire if clothing, bedding, and other flammable objects are nearby. An escape route is very important, but successfully escaping also depends on early recognition of a fire, which is assisted by smoke detectors. DIF: Cognitive Level: Comprehension/Understanding

418-419 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 3. The nurse assesses a circular, flat, reddened lesion about 5 cm in diameter on a middle-aged patients ankle. How should the nurse determine if the lesion is related to intradermal bleeding? a. Elevate the patients leg. b. Press firmly on the lesion. c. Check the temperature of the skin around the lesion. d. Palpate the dorsalis pedis and posterior tibial pulses.

B If the lesion is caused by intradermal or subcutaneous bleeding or a nonvascular cause, the discoloration will remain when direct pressure is applied to the lesion. If the lesion is caused by blood vessel dilation, blanching will occur with direct pressure. The other assessments will assess circulation to the leg, but will not be helpful in determining the etiology of the lesion. DIF: Cognitive Level: Apply (application)

421 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 10. A patient reports chronic itching of the ankles and continuously scratches the area. Which assessment finding will the nurse expect? a. Hypertrophied scars on both ankles b. Thickening of the skin around the ankles c. Yellowish-brown skin around both ankles d. Complete absence of melanin in both ankles

B Lichenification is likely to occur in areas where the patient scratches the skin frequently. Lichenification results in thickening of the skin with accentuated normal skin markings. Vitiligo is the complete absence of melanin in the skin. Keloids are hypertrophied scars. Yellowish-brown skin indicates jaundice. Vitiligo, keloids, and jaundice do not usually occur as a result of scratching the skin. DIF: Cognitive Level: Understand (comprehension)

p. 463 TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationAlterations in Body Systems) MSC: Integrated Process: Nursing Process (Assessment) 16. On assessing a clients lower extremities, the nurse notices that one leg is pale and cooler to the touch. Which assessment does the nurse perform next? a. Ask about a family history of skin disorders. b. Palpate the clients pedal pulses bilaterally. c. Check for the presence of Homans sign. d. Assess the clients skin for adequate skin turgor.

B Localized, decreased skin temperature and pallor indicate interference with vascular flow to the region. The nurse should assess bilateral pedal pulses to screen for vascular sufficiency. Without adequate blood flow, the clients limb could be threatened. Asking about a family history of skin problems would not take priority over assessing blood flow. Homans sign is a screening tool for deep vein thrombosis and is often inaccurate. Skin turgor gives information about hydration status. This assessment may be needed but certainly does not take priority over assessing for blood flow. DIF: Cognitive Level: Application/Applying or higher

443 KEY: Skin breakdown MSC: Integrated Process: Nursing Process: Assessment NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care 6. After educating a caregiver of a home care client, a nurse assesses the caregivers understanding. Which statement indicates that the caregiver needs additional education? a. I can help him shift his position every hour when he sits in the chair. b. If his tailbone is red and tender in the morning, I will massage it with baby oil. c. Applying lotion to his arms and legs every evening will decrease dryness. d. Drinking a nutritional supplement between meals will help maintain his weight.

B Massage of reddened areas over bony prominences such as the coccyx, or tailbone, is contraindicated because the pressure of the massage can cause damage to the skin and subcutaneous tissue layers. The other statements are appropriate for the care of a client at home. DIF: Applying/Application

N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for Complications from Surgical Procedures and Health Alterations) MSC: Integrated Process: Nursing Process (Implementation) 33. A client has severe burns around the right hip. Which position does the nurse instruct the nursing assistant to use to maintain maximum function of this joint? a. Hip maintained in 30-degree flexion b. Hip at zero flexion with leg flat c. Knee flexed at 30-degree angle d. Leg abducted with foam wedge

B Maximum function for ambulation occurs when the hip and the leg are maintained at full extension with neutral rotation. Although the client does not have to spend 24 hours in this position, he or she should be in this position (in bed or standing) longer than with the hip in any degree of flexion. DIF: Cognitive Level: Comprehension/Understanding

444 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 15. The nurse is interviewing a patient with contact dermatitis. Which finding indicates a need for patient teaching? a. The patient applies corticosteroid cream to pruritic areas. b. The patient uses Neosporin ointment on minor cuts or abrasions. c. The patient adds oilated oatmeal (Aveeno) to the bath water every day. d. The patient takes diphenhydramine (Benadryl) at night if itching occurs.

B Neosporin can cause contact dermatitis. The other medications are being used appropriately by the patient. DIF: Cognitive Level: Apply (application)

436 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 8. A teenaged male patient who wrestles in high school is examined by the nurse in the clinic. Which assessment finding would prompt the nurse to teach the patient about the importance of not sharing headgear to prevent the spread of pediculosis? a. Ringlike rashes with red, scaly borders over the entire scalp b. Papular, wheal-like lesions with white deposits on the hair shaft c. Patchy areas of alopecia with small vesicles and excoriated areas d. Red, hivelike papules and plaques with sharply circumscribed borders

B Pediculosis is characterized by wheal-like lesions with parasites that attach eggs to the base of the hair shaft. The other descriptions are more characteristic of other types of skin disorders. DIF: Cognitive Level: Understand (comprehension)

N/A TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationMedical Emergencies) MSC: Integrated Process: Nursing Process (Implementation) 16. A client who is receiving fluid resuscitation per the Parkland formula after a serious burn continues to have urine output ranging from 0.2 to 0.25 mL/kg/hour. After the health care provider checks the client, which order does the nurse question? a. Increase IV fluids by 100 mL/hr. b. Administer furosemide (Lasix) 40 mg IV push. c. Continue to monitor urine output hourly. d. Draw blood for serum electrolytes stat.

B Postburn fluid needs are calculated initially by using a standardized formula such as the Parkland formula. However, needs vary among clients, and the final fluid volume needed is adjusted to maintain hourly urine output at 0.5 mL/kg/hr. Based on this clients inadequate urine output, fluids need to be increased. The other orders are appropriate. DIF: Cognitive Level: Application/Applying or higher

449 KEY: Skin lesions/wounds| case management MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation 13. After teaching a client who has psoriasis, a nurse assesses the clients understanding. Which statement indicates the client needs additional teaching? a. At the next family reunion, Im going to ask my relatives if they have psoriasis. b. I have to make sure I keep my lesions covered, so I do not spread this to others. c. I expect that these patches will get smaller when I lie out in the sun. d. I should continue to use the cortisone ointment as the patches shrink and dry out.

B Psoriasis is not a contagious disorder. The client does not have to worry about spreading the condition to others. It is a condition that has hereditary links, the patches will decrease in size with ultraviolet light exposure, and cortisone ointment should be applied directly to lesions to suppress cell division. DIF: Applying/Application

1. While assessing a client, a nurse detects a bluish tinge to the clients palms, soles, and mucous membranes. Which action should the nurse take next? a. Ask the client about current medications he or she is taking. b. Use pulse oximetry to assess the clients oxygen saturation. c. Auscultate the clients lung fields for adventitious sounds. d. Palpate the clients bilateral radial and pedal pulses.

B Cyanosis can be present when impaired gas exchange occurs. In a client with dark skin, cyanosis can be seen because the palms, soles, and mucous membranes have a bluish tinge. The nurse should assess for systemic oxygenation before continuing with other assessments. DIF: Applying/Application

N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for Alterations in Body Systems) MSC: Integrated Process: Nursing Process (Implementation) 23. A client has experienced an electrical injury of the lower extremities. Which priority assessment data should be obtained from this client? a. Range of motion in all extremities b. Heart rate, rhythm, and electrocardiogram (ECG) c. Respiratory rate and pulse oximetry d. Orientation to time, place, and person

B The airway is not at any particular risk with this injury. Therefore, respiratory rate and pulse oximetry are not priority assessments. Electrical current travels through the body from the entrance site to the exit site and can seriously damage all tissues between the two sites. Early cardiac damage from electrical injury includes irregular heart rate and rhythm, and ECG changes. Range-of-motion and neurologic assessments are important; however, the priority is to make sure that the heart rate and rhythm are adequate to support perfusion to the brain and other vital organs. DIF: Cognitive Level: Application/Applying or higher

p. 515 TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationPathophysiology) MSC: Integrated Process: Nursing Process (Assessment) 12. A client has a large burned area on the right arm. The burned area appears pink, has blisters, and is very painful. How does the nurse categorize this injury? a. Full thickness b. Partial thickness superficial c. Partial thickness deep d. Superficial

B The characteristics of the wound meet the criteria for a superficial partial-thickness injury: color that is pink or red; blisters; and pain. Blisters are not seen with full-thickness and superficial burns and are rarely seen with deep partial-thickness burns. Deep partial-thickness burns appear red to white. DIF: Cognitive Level: Comprehension/Understanding

N/A TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationPathophysiology) MSC: Integrated Process: Teaching/Learning 13. A client comes to the clinic reporting pain and itching from blisters on both arms. This finding indicates an abnormality in which layer of the skin? a. Adipose tissue b. Dermis c. Epidermis d. Stratum corneum

B The dermis or dermal layer of the skin contains sensory nerves that transmit sensations of touch, pressure, temperature, pain, and itch. DIF: Cognitive Level: Knowledge/Remembering

257 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity 3. A patient is admitted to the burn unit with burns to the head, face, and hands. Initially, wheezes are heard, but an hour later, the lung sounds are decreased and no wheezes are audible. What is the best action for the nurse to take? a. Encourage the patient to cough and auscultate the lungs again. b. Notify the health care provider and prepare for endotracheal intubation. c. Document the results and continue to monitor the patients respiratory rate. d. Reposition the patient in high-Fowlers position and reassess breath sounds.

B The patients history and clinical manifestations suggest airway edema and the health care provider should be notified immediately, so that intubation can be done rapidly. Placing the patient in a more upright position or having the patient cough will not address the problem of airway edema. Continuing to monitor is inappropriate because immediate action should occur. DIF: Cognitive Level: Apply (application)

474 KEY: Medical emergency| respiratory distress/failure MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care 10. A nurse receives new prescriptions for a client with severe burn injuries who is receiving fluid resuscitation per the Parkland formula. The clients urine output continues to range from 0.2 to 0.25 mL/kg/hr. Which prescription should the nurse question? a. Increase intravenous fluids by 100 mL/hr. b. Administer furosemide (Lasix) 40 mg IV push. c. Continue to monitor urine output hourly. d. Draw blood for serum electrolytes STAT.

B The plan of care for a client with a burn includes fluid and electrolyte resuscitation. Furosemide would be inappropriate to administer. Postburn fluid needs are calculated initially by using a standardized formula such as the Parkland formula. However, needs vary among clients, and the final fluid volume needed is adjusted to maintain hourly urine output at 0.5 mL/kg/hr. Based on this clients inadequate urine output, fluids need to be increased, urine output needs to be monitored hourly, and electrolytes should be evaluated to ensure appropriate fluids are being infused. DIF: Applying/Application

438 KEY: Skin breakdown MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Health Promotion and Maintenance 7. After teaching a client who is at risk for the formation of pressure ulcers, a nurse assesses the clients understanding. Which dietary choice by the client indicates a good understanding of the teaching? a. Low-fat diet with whole grains and cereals and vitamin supplements b. High-protein diet with vitamins and mineral supplements c. Vegetarian diet with nutritional supplements and fish oil capsules d. Low-fat, low-cholesterol, high-fiber, low-carbohydrate diet

B The preferred diet is high in protein to assist in wound healing and prevention of new wounds. Fat is also needed to ensure formation of cell membranes, so any of the options with low fat would not be good choices. A vegetarian diet would not provide fat and high levels of protein. DIF: Applying/Application

461 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 8. A nurse is caring for a patient who has burns of the ears, head, neck, and right arm and hand. The nurse should place the patient in which position? a. Place the right arm and hand flexed in a position of comfort. b. Elevate the right arm and hand on pillows and extend the fingers. c. Assist the patient to a supine position with a small pillow under the head. d. Position the patient in a side-lying position with rolled towel under the neck.

B The right hand and arm should be elevated to reduce swelling and the fingers extended to avoid flexion contractures (even though this position may not be comfortable for the patient). The patient with burns of the ears should not use a pillow for the head because this will put pressure on the ears, and the pillow may stick to the ears. Patients with neck burns should not use a pillow because the head should be maintained in an extended position in order to avoid contractures. DIF: Cognitive Level: Apply (application)

459 KEY: Skin lesions/wounds MSC: Integrated Process: Nursing Process: Assessment NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 22. A nurse evaluates the following data in a clients chart: Admission Note Laboratory Results Wound Care Note 66-year-old male with a health history of a cerebral vascular accident and left-side paralysis White blood cell count: 8000/mm3 Prealbumin: 15.2 mg/dL Albumin: 4.2 mg/dL Lymphocyte count: 2000/mm3 Sacral ulcer 4 cm 2 cm 1.5 cm Based on this information, which action should the nurse take? a. Perform a neuromuscular assessment. b. Request a dietary consult. c. Initiate Contact Precautions. d. Assess the clients vital signs.

B The white blood cell count is not directly related to nutritional status. Albumin, prealbumin, and lymphocyte counts all give information related to nutritional status. The prealbumin count is a more specific indicator of nutritional status than is the albumin count. The albumin and lymphocyte counts given are normal, but the prealbumin count is low. This puts the client at risk for inadequate wound healing, so the nurse should request a dietary consult. The other interventions do not address the information provided. DIF: Analyzing/Analysis

480 KEY: Pain management MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 16. A nurse cares for a client with burn injuries from a house fire. The client is not consistently oriented and reports a headache. Which action should the nurse take? a. Increase the clients oxygen and obtain blood gases. b. Draw blood for a carboxyhemoglobin level. c. Increase the clients intravenous fluid rate. d. Perform a thorough Mini-Mental State Examination.

B These manifestations are consistent with moderated carbon monoxide poisoning. This client is at risk for carbon monoxide poisoning because he or she was in a fire in an enclosed space. The other options will not provide information related to carbon monoxide poisoning. DIF: Applying/Application

Chart 28-6, p. 537 TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for Complications from Surgical Procedures and Health Alterations) MSC: Integrated Process: Nursing Process (Implementation) 34. A client who suffered burns in a house fire reports a headache and is not consistently oriented to time. Which intervention by the nurse is most appropriate? a. Increase the clients oxygen and obtain blood gases. b. Draw blood for a carboxyhemoglobin level. c. Increase the clients intravenous fluid rate. d. Perform a thorough Mini-Mental Status Examination.

B These manifestations are consistent with moderated carbon monoxide poisoning. This client is at risk for carbon monoxide poisoning because he or she was in a fire in an enclosed space. The other options will not provide information related to carbon monoxide poisoning. DIF: Cognitive Level: Application/Applying or higher

456 KEY: Skin lesions/wounds MSC: Integrated Process: Nursing Process: Evaluation NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation 14. A nurse performs a skin screening for a client who has numerous skin lesions. Which lesion does the nurse evaluate first? a. Beige freckles on the backs of both hands b. Irregular blue mole with white specks on the lower leg c. Large cluster of pustules in the right axilla d. Thick, reddened papules covered by white scales

B This mole fits two of the criteria for being cancerous or precancerous: variation of color within one lesion, and an indistinct or irregular border. Melanoma is an invasive malignant disease with the potential for a fatal outcome. Freckles are a benign condition. Pustules could mean an infection, but it is more important to take care of the potentially cancerous lesion first. Psoriasis vulgaris manifests as thick reddened papules covered by white scales. This is a chronic disorder and is not the priority. DIF: Applying/Application

468-469 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity 28. A young adult patient who is in the rehabilitation phase 6 months after a severe face and neck burn tells the nurse, Im sorry that Im still alive. My life will never be normal again. Which response by the nurse is best? a. Most people recover after a burn and feel satisfied with their lives. b. Its true that your life may be different. What concerns you the most? c. It is really too early to know how much your life will be changed by the burn. d. Why do you feel that way? You will be able to adapt as your recovery progresses.

B This response acknowledges the patients feelings and asks for more assessment data that will help in developing an appropriate plan of care to assist the patient with the emotional response to the burn injury. The other statements are accurate, but do not acknowledge the anxiety and depression that the patient is expressing. DIF: Cognitive Level: Apply (application)

463 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity 7. While the patients fullthickness burn wounds to the face are exposed, what is the best nursing action to prevent cross contamination? a. Use sterile gloves when removing old dressings. b. Wear gowns, caps, masks, and gloves during all care of the patient. c. Administer IV antibiotics to prevent bacterial colonization of wounds. d. Turn the room temperature up to at least 70 F (20 C) during dressing changes.

B Use of gowns, caps, masks, and gloves during all patient care will decrease the possibility of wound contamination for a patient whose burns are not covered. When removing contaminated dressings and washing the dirty wound, use nonsterile, disposable gloves. The room temperature should be kept at approximately 85 F for patients with open burn wounds to prevent shivering. Systemic antibiotics are not well absorbed into deep burns because of the lack of circulation. DIF: Cognitive Level: Apply (application)

443-444 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 1. When assessing a patient who spilled hot oil on the right leg and foot, the nurse notes that the skin is dry, pale, hard skin. The patient states that the burn is not painful. What term would the nurse use to document the burn depth? a. First-degree skin destruction b. Full-thickness skin destruction c. Deep partial-thickness skin destruction d. Superficial partial-thickness skin destruction

B With full-thickness skin destruction, the appearance is pale and dry or leathery and the area is painless because of the associated nerve destruction. Erythema, swelling, and blisters point to a deep partial-thickness burn. With superficial partial-thickness burns, the area is red, but no blisters are present. First-degree burns exhibit erythema, blanching, and pain. DIF: Cognitive Level: Understand (comprehension)

422 KEY: Anemia MSC: Integrated Process: Nursing Process: Assessment NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 11. During skin inspection of a client, a nurse observes lesions with wavy borders that are widespread across the clients chest. Which descriptors should the nurse use to document these observations? a. Clustered and annular b. Linear and circinate c. Diffuse and serpiginous d. Coalesced and circumscribed

B Diffuse is used to describe lesions that are widespread. Serpiginous describes lesions with wavy borders. Clustered describes lesions grouped together. Linear describes lesions occurring in a straight line. Annular lesions are ringlike with raised borders, circinate lesions are circular, and circumscribed lesions have well-defined sharp borders. Coalesced describes lesions that merge with one another and appear confluent. DIF: Remembering/Knowledge

423 KEY: Skin lesions/wounds| documentation MSC: Integrated Process: Communication and Documentation NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation 6. While assessing a clients lower extremities, a nurse notices that one leg is pale and cooler to the touch. Which assessment should the nurse perform next? a. Ask about a family history of skin disorders. b. Palpate the clients pedal pulses bilaterally. c. Check for the presence of Homans sign. d. Assess the clients skin for adequate skin turgor.

B Localized, decreased skin temperature and pallor indicate interference with vascular flow to the region. The nurse should assess bilateral pedal pulses to screen for vascular sufficiency. Without adequate blood flow, the clients limb could be threatened. Asking about a family history of skin problems would not take priority over assessing blood flow. Homans sign is a screening tool for deep vein thrombosis and is often inaccurate. Skin turgor gives information about hydration status. This assessment may be needed but certainly does not take priority over assessing for blood flow. DIF: Applying/Application

428 KEY: Skin lesions/wounds| coping MSC: Integrated Process: Nursing Process: Assessment NOT: Client Needs Category: Psychosocial Integrity 10. A nurse assesses a client and identifies that the client has pallor conjunctivae. Which focused assessment should the nurse complete next? a. Partial thromboplastin time b. Hemoglobin and hematocrit c. Liver enzymes d. Basic metabolic panel

B Pallor conjunctivae signifies anemia. The nurse should assess the clients hemoglobin and hematocrit to confirm anemia. The other laboratory results do not relate to this clients potential anemia. DIF: Applying/Application

438 KEY: Skin breakdown MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 3. A nurse prepares to admit a client who has herpes zoster. Which actions should the nurse take? (Select all that apply.) a. Prepare a room for reverse isolation. b. Assess staff for a history of or vaccination for chickenpox. c. Check the admission orders for analgesia. d. Choose a roommate who also is immune suppressed. e. Ensure that gloves are available in the room.

B, C, E Herpes zoster (shingles) is caused by reactivation of the same virus, varicella zoster, in clients who have previously had chickenpox. Anyone who has not had the disease or has not been vaccinated for it is at high risk for getting chickenpox. Herpes zoster is very painful and requires analgesia. Use of gloves and good handwashing are sufficient to prevent spread. It is best to put this client in a private room. Herpes zoster is a disease of immune suppression, so no one who is immune-suppressed should be in the same room. DIF: Applying/Application

438 KEY: Skin breakdown MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care 5. A nurse assesses a client who presents with an increase in psoriatic lesions. Which questions should the nurse ask to identify a possible trigger for worsening of this clients psoriatic lesions? (Select all that apply.) a. Have you eaten a large amount of chocolate lately? b. Have you been under a lot of stress lately? c. Have you recently used a public shower? d. Have you been out of the country recently? e. Have you recently had any other health problems? f. Have you changed any medications recently?

B, E, F Systemic factors, hormonal changes, psychological stress, medications, and general health factors can aggravate psoriasis. Psoriatic lesions are not triggered by chocolate, public showers, or international travel. DIF: Applying/Application

446 KEY: Skin breakdown| nutrition MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Health Promotion and Maintenance 8. A nurse assesses clients on a medical-surgical unit. Which client should the nurse evaluate for a wound infection? a. Client with blood cultures pending b. Client who has thin, serous wound drainage c. Client with a white blood cell count of 23,000/mm3 d. Client whose wound has decreased in size

C A client with an elevated white blood cell count should be evaluated for sources of infection. Pending cultures, thin drainage, and a decrease in wound size are not indications that the client may have an infection. DIF: Applying/Application

464 TOP: Nursing Process: Application MSC: NCLEX: Physiological Integrity 14. A patient with burns covering 40% total body surface area (TBSA) is in the acute phase of burn treatment. Which snack would be best for the nurse to offer to this patient? a. Bananas b. Orange gelatin c. Vanilla milkshake d. Whole grain bagel

C A patient with a burn injury needs high protein and calorie food intake, and the milkshake is the highest in these nutrients. The other choices are not as nutrient-dense as the milkshake. Gelatin is likely high in sugar. The bagel is a good carbohydrate choice, but low in protein. Bananas are a good source of potassium, but are not high in protein and calories. DIF: Cognitive Level: Apply (application)

N/A TOP: Client Needs Category: Health Promotion and Maintenance (Aging Process) MSC: Integrated Process: Nursing Process (Planning) 2. A client has a suspected superficial fungal infection. The nurse prepares the client for a culture by explaining the procedure. Which statement by the client indicates a correct understanding of the procedure? a. The doctor will shave off a small piece of the lesion. b. You will be performing what is called a punch biopsy. c. A sample is obtained by simply scraping the lesion. d. Youll squeeze material from the lesion to send to the laboratory.

C A superficial fungal culture is obtained by gently scraping the lesion with a tongue blade. The other techniques are not used for a suspected superficial fungal infection. DIF: Cognitive Level: Application/Applying or higher

474 KEY: Respiratory distress/failure| medical emergency MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation 19. A nurse uses the rule of nines to assess a client with burn injuries to the entire back region and left arm. How should the nurse document the percentage of the clients body that sustained burns? a. 9% b. 18% c. 27% d. 36%

C According to the rule of nines, the posterior trunk, anterior trunk, and legs each make up 18% of the total body surface. The head, neck, and arms each make up 9% of total body surface, and the perineum makes up 1%. In this case, the client received burns to the back (18%) and one arm (9%), totaling 27% of the body. DIF: Applying/Application

452 | 455 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 19. A patient with extensive electrical burn injuries is admitted to the emergency department. Which prescribed intervention should the nurse implement first? a. Assess oral temperature. b. Check a potassium level. c. Place on cardiac monitor. d. Assess for pain at contact points.

C After an electrical burn, the patient is at risk for fatal dysrhythmias and should be placed on a cardiac monitor. Assessing the oral temperature is not as important as assessing for cardiac dysrhythmias. Checking the potassium level is important. However, it will take time before the laboratory results are back. The first intervention is to place the patient on a cardiac monitor and assess for dysrhythmias, so that they can be treated if occurring. A decreased or increased potassium level will alert the nurse to the possibility of dysrhythmias. The cardiac monitor will alert the nurse immediately of any dysrhythmias. Assessing for pain is important, but the patient can endure pain until the cardiac monitor is attached. Cardiac dysrhythmias can be lethal. DIF: Cognitive Level: Analyze (analysis)

467 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity 15. A patient has just arrived in the emergency department after an electrical burn from exposure to a high-voltage current. What is the priority nursing assessment? a. Oral temperature b. Peripheral pulses c. Extremity movement d. Pupil reaction to light

C All patients with electrical burns should be considered at risk for cervical spine injury, and assessments of extremity movement will provide baseline data. The other assessment data are also necessary but not as essential as determining the cervical spine status. DIF: Cognitive Level: Apply (application)

N/A TOP: Client Needs Category: Psychosocial Integrity (Coping Mechanisms) MSC: Integrated Process: Nursing Process (Evaluation) 8. Which statement best exemplifies a clients understanding of rehabilitation after a full-thickness burn injury? a. I am fully recovered when all the wounds are closed. b. I will eventually be able to perform all my former activities. c. My goal is to achieve the highest level of functioning that I can. d. Full recovery from a major burn injury never occurs.

C Although a return to preburn functional levels is rarely possible, burned clients are considered fully recovered or rehabilitated when they have achieved their highest possible level of physical, social, and emotional functioning. The technical rehabilitative phase of rehabilitation begins with wound closure and ends when the client returns to her or his highest possible level of functioning. DIF: Cognitive Level: Application/Applying or higher

422 TOP: Nursing Process: Implementation MSC: NCLEX: Health Promotion and Maintenance 8. A patient in the dermatology clinic is scheduled for removal of a 15-mm multicolored and irregular mole from the upper back. The nurse should prepare the patient for which type of biopsy? a. Shave biopsy b. Punch biopsy c. Incisional biopsy d. Excisional biopsy

C An incisional biopsy would remove the entire mole and the tissue borders. The appearance of the mole indicates that it may be malignant. A shave biopsy would not remove the entire mole. The mole is too large to be removed with punch biopsy. Excisional biopsies are done for smaller lesions and where a good cosmetic effect is desired, such as on the face. DIF: Cognitive Level: Apply (application)

433 KEY: Hygiene| skin breakdown MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Physiological Integrity: Basic Care and Comfort 2. A nurse assesses clients on a medical-surgical unit. Which client is at greatest risk for pressure ulcer development? a. A 44-year-old prescribed IV antibiotics for pneumonia b. A 26-year-old who is bedridden with a fractured leg c. A 65-year-old with hemi-paralysis and incontinence d. A 78-year-old requiring assistance to ambulate with a walker

C Being immobile and being incontinent are two significant risk factors for the development of pressure ulcers. The client with pneumonia does not have specific risk factors. The young client who has a fractured leg and the client who needs assistance with ambulation might be at moderate risk if they do not move about much, but having two risk factors makes the 65-year-old the person at highest risk. DIF: Applying/Application

436 KEY: Skin breakdown| Braden Scale MSC: Integrated Process: Nursing Process: Assessment NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 3. When transferring a client into a chair, a nurse notices that the pressure-relieving mattress overlay has deep imprints of the clients buttocks, heels, and scapulae. Which action should the nurse take next? a. Turn the mattress overlay to the opposite side. b. Do nothing because this is an expected occurrence. c. Apply a different pressure-relieving device. d. Reinforce the overlay with extra cushions.

C Bottoming out, as evidenced by deep imprints in the mattress overlay, indicates that this device is not appropriate for this client, and a different device or strategy should be implemented to prevent pressure ulcer formation. DIF: Applying/Application

442 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity 20. The nurse instructs a patient about application of corticosteroid cream to an area of contact dermatitis on the right leg. Which patient action indicates that further teaching is needed? a. The patient takes a tepid bath before applying the cream. b. The patient spreads the cream using a downward motion. c. The patient applies a thick layer of the cream to the affected skin. d. The patient covers the area with a dressing after applying the cream.

C Creams and ointments should be applied in a thin layer to avoid wasting the medication. The other actions by the patient indicate that the teaching has been successful. DIF: Cognitive Level: Apply (application)

N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialLaboratory Tests) MSC: Integrated Process: Nursing Process (Analysis) 35. A client who has had a full-thickness burn is being discharged from the hospital. Which information is most important for the nurse to provide before discharge? a. How to maintain home smoke detectors b. Joining a community reintegration program c. Learning to perform dressing changes d. Options available for scar removal

C Critical for the goal of progression toward independence for the client is teaching clients and family members to perform care tasks such as dressing changes. All of the other options are important in the rehabilitation stage. However, dressing changes have priority. DIF: Cognitive Level: Application/Applying or higher

421 TOP: Nursing Process: Implementation MSC: NCLEX: Health Promotion and Maintenance 5. A dark-skinned patient has been admitted to the hospital with chronic heart failure. How would the nurse best assess this patient for cyanosis? a. Assess the skin color of the earlobes. b. Apply pressure to the palms of the hands. c. Check the lips and oral mucous membranes. d. Examine capillary refill time of the nail beds.

C Cyanosis in dark-skinned individuals is more easily seen in the mucous membranes. Earlobe color may change in light-skinned individuals, but this change in skin color is difficult to detect on darker skin. Application of pressure to the palms of the hands and nail bed assessment would check for adequate circulation but not for skin color. DIF: Cognitive Level: Apply (application)

N/A TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationMedical Emergencies) MSC: Integrated Process: Nursing Process (Implementation) 22. A client suffered a 45% total body surface area (TBSA) burn and was intubated. Twelve hours later, bowel sounds were absent in all four abdominal quadrants. Which is the nurses best action? a. Administer a laxative. b. Document the finding. c. Prepare to insert a nasogastric (NG) tube. d. Reposition the client on the right side.

C Decreased or absent peristalsis is a frequent response during the emergent phase of burn injury as a result of neural and hormonal compensation to the stress of injury. The result is often a paralytic ileus. Clients who have burns greater than 25% TBSA or who are intubated generally need to have an NG tube inserted. DIF: Cognitive Level: Application/Applying or higher

421 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 6. The nurse prepares to obtain a culture from a patient who has a possible fungal infection on the foot. Which items should the nurse gather for this procedure? a. Sterile gloves b. Patch test instruments c. Cotton-tipped applicators d. Local anesthetic, syringe, and intradermal needle

C Fungal cultures are obtained by swabbing the affected area of the skin with cotton-tipped applicators. Sterile gloves are not needed because it is not a sterile procedure. Local injection is not needed because the swabbing is not usually painful. The patch test is done to determine whether a patient is allergic to specific testing material, not for obtaining fungal specimens. DIF: Cognitive Level: Apply (application)

459 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 4. A patient with severe burns has crystalloid fluid replacement ordered using the Parkland formula. The initial volume of fluid to be administered in the first 24 hours is 30,000 mL. The initial rate of administration is 1875 mL/hr. After the first 8 hours, what rate should the nurse infuse the IV fluids? a. 350 mL/hour b. 523 mL/hour c. 938 mL/hour d. 1250 mL/hour

C Half of the fluid replacement using the Parkland formula is administered in the first 8 hours and the other half over the next 16 hours. In this case, the patient should receive half of the initial rate, or 938 mL/hr. DIF: Cognitive Level: Apply (application)

p. 468 TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialSystem-Specific Assessments) MSC: Integrated Process: Teaching/Learning 12. A client expresses concern about a rash located beneath her breast. What statement by the client indicates a good understanding of this condition? a. This rash is probably due to fluid overload. b. I need to wash this daily with antibacterial soap. c. I can use powder to keep this area dry. d. I will schedule a mammogram as soon as I can.

C Rashes limited to skin-fold areas (e.g., on the axillae, beneath the breasts, in the groin) may reflect problems related to excessive moisture. The client needs to keep the area dry; one option is to use powder. Good hygiene is important, but the rash does not need an antibacterial soap. The other two options are not related to rashes in skin folds. DIF: Cognitive Level: Application/Applying or higher

485 KEY: Infection control| Standard Precautions MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control 3. The nurse teaches burn prevention to a community group. Which statement by a member of the group should cause the nurse the greatest concern? a. I get my chimney swept every other year. b. My hot water heater is set at 120 degrees. c. Sometimes I wake up at night and smoke. d. I use a space heater when it gets below zero.

C House fires are a common occurrence and often lead to serious injury or death. The nurse should be most concerned about a person who wakes up at night and smokes. The nurse needs to question this person about whether he or she gets out of bed to do so, or if this person stays in bed, which could lead to falling back asleep with a lighted cigarette. Although it is recommended to have chimneys swept every year, skipping a year does not pose as much danger as smoking in bed, particularly if the person does not burn wood frequently. Water heaters should be set below 140 F. Space heaters should be used with caution, and the nurse may want to ensure that the person does not allow it to get near clothing or bedding. DIF: Applying/Application

N/A TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection ControlStandard Precautions/Transmission-Based Precautions/Surgical Asepsis) MSC: Integrated Process: Nursing Process (Implementation) 3. The nurse is teaching burn prevention to a community group. Which information shared by a member of the group causes the nurse the greatest concern? a. I get my chimneys swept every other year. b. My hot water heater is set at about 120 degrees. c. Sometimes I wake up at night and smoke. d. I use a space heater when it gets below zero.

C House fires are a common occurrence and often lead to serious injury or death. The nurse should be most concerned about a person who wakes up at night and smokes. The nurse needs to question this person about whether he or she gets out of bed to do so, or if this person stays in bed, which could lead to falling back asleep with a lighted cigarette. Although it is recommended to have chimneys swept every year, skipping a year does not pose as much danger as smoking in bed, particularly if the person does not burn wood frequently. Water heaters should be set below 140 F. Space heaters should be used with caution, and the nurse may want to ensure that the person does not allow it to get near clothing or bedding. But the most immediate concern is the persons smoking upon waking up at night. DIF: Cognitive Level: Application/Applying or higher

455 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 24. The nurse is reviewing laboratory results on a patient who had a large burn 48 hours ago. Which result requires priority action by the nurse? a. Hematocrit 53% b. Serum sodium 147 mEq/L c. Serum potassium 6.1 mEq/L d. Blood urea nitrogen 37 mg/dL

C Hyperkalemia can lead to fatal dysrhythmias and indicates that the patient requires cardiac monitoring and immediate treatment to lower the potassium level. The other laboratory values are also abnormal and require changes in treatment, but they are not as immediately life threatening as the elevated potassium level. DIF: Cognitive Level: Apply (application)

N/A TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationIllness Management) MSC: Integrated Process: Nursing Process (Evaluation) 7. Which finding indicates to the nurse that a client with a burn injury has a positive perception of his appearance? a. Allowing family members to change the dressings b. Discussing future surgical reconstruction c. Performing morning care independently d. Wearing the pressure dressings as ordered

C Indicators that the client with a burn injury has a positive perception of his appearance include his or her willingness to touch the affected body part. Self-care activities such as morning care foster feelings of self-worth, which are closely linked to body image. Allowing others to change the dressing and discussing future reconstruction would not indicate a positive perception of appearance. Wearing the dressing will assist in decreasing complications but will not enhance self-perception. DIF: Cognitive Level: Application/Applying or higher

488 KEY: Psychosocial response| patient education MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Psychosocial Integrity 5. A nurse assesses a client who has a burn injury. Which statement indicates the client has a positive perspective of his or her appearance? a. I will allow my spouse to change my dressings. b. I want to have surgical reconstruction. c. I will bathe and dress before breakfast. d. I have secured the pressure dressings as ordered.

C Indicators that the client with a burn injury has a positive perception of his or her appearance include a willingness to touch the affected body part. Self-care activities such as morning care foster feelings of self-worth, which are closely linked to body image. Allowing others to change the dressing and discussing future reconstruction would not indicate a positive perception of appearance. Wearing the dressing will assist in decreasing complications but will not enhance self-perception. DIF: Applying/Application

p. 517 TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral TherapiesExpected Actions/Outcomes) MSC: Integrated Process: Teaching/Learning 14. A client who is burned is drooling and is having difficulty swallowing. Which action does the nurse take first? a. Assess level of consciousness and pupillary reactions. b. Ascertain the time food or liquid was last consumed. c. Auscultate breath sounds over the trachea and mainstem bronchi. d. Measure abdominal girth and auscultate bowel sounds.

C Inhalation injuries are present in 7% of clients admitted to burn centers. Drooling and difficulty swallowing can mean that the client is about to lose his airway because of this injury. Absence of breath sounds over the trachea and mainstem bronchi indicates impending airway obstruction and demands immediate intubation. Knowing the level of consciousness is important in assessing oxygenation to the brain. Ascertaining the time of last food intake is important, in case intubation is necessary (the nurse will be more alert for signs of aspiration). However, assessing for air exchange is the most important intervention at this time. Measuring abdominal girth is not relevant in this situation. DIF: Cognitive Level: Application/Applying or higher

470 KEY: Medication| patient education| peptic ulcer disease prophylaxis MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 9. A nurse cares for a client with a burn injury who presents with drooling and difficulty swallowing. Which action should the nurse take first? a. Assess the level of consciousness and pupillary reactions. b. Ascertain the time food or liquid was last consumed. c. Auscultate breath sounds over the trachea and bronchi. d. Measure abdominal girth and auscultate bowel sounds.

C Inhalation injuries are present in 7% of clients admitted to burn centers. Drooling and difficulty swallowing can mean that the client is about to lose his or her airway because of this injury. Absence of breath sounds over the trachea and bronchi indicates impending airway obstruction and demands immediate intubation. Knowing the level of consciousness is important in assessing oxygenation to the brain. Ascertaining the time of last food intake is important in case intubation is necessary (the nurse will be more alert for signs of aspiration). However, assessing for air exchange is the most important intervention at this time. Measuring abdominal girth is not relevant in this situation. DIF: Applying/Application

451 KEY: Infection| antibiotic| medication administration MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 16. A nurse assesses a young female client who is prescribed isotretinoin (Accutane). Which question should the nurse ask prior to starting this therapy? a. Do you spend a great deal of time in the sun? b. Have you or any family members ever had skin cancer? c. Which method of contraception are you using? d. Do you drink alcoholic beverages?

C Isotretinoin has many side effects. It is a known teratogen and can cause severe birth defects. A pregnancy test is required before therapy is initiated, and strict birth control measures must be used during therapy. Sun exposure, alcohol ingestion, and family history of cancer are contraindications for isotretinoin. DIF: Applying/Application

p. 520 TOP: Client Needs Category: Health Promotion and Maintenance (Health Promotion/Disease Prevention) MSC: Integrated Process: Teaching/Learning 5. A client with facial burns asks the nurse if he will ever look the same. Which response is best for the nurse to provide? a. With reconstructive surgery, you can look the same. b. We can remove the scars with the use of a pressure dressing. c. You will not look exactly the same but cosmetic surgery will help. d. You shouldnt start worrying about your appearance right now.

C Many clients have unrealistic expectations of reconstructive surgery and envision an appearance identical or equal in quality to the preburn state. The nurse should provide accurate information that includes something to hope for. Pressure dressings prevent further scarring. They cannot remove scars. The client and the family should be taught the expected cosmetic outcomes. DIF: Cognitive Level: Application/Applying or higher

472 KEY: Safety| smoking cessation MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Health Promotion and Maintenance 4. A nurse cares for a client who has facial burns. The client asks, Will I ever look the same? How should the nurse respond? a. With reconstructive surgery, you can look the same. b. We can remove the scars with the use of a pressure dressing. c. You will not look exactly the same but cosmetic surgery will help. d. You shouldnt start worrying about your appearance right now.

C Many clients have unrealistic expectations of reconstructive surgery and envision an appearance identical or equal in quality to the preburn state. The nurse should provide accurate information that includes something to hope for. Pressure dressings prevent further scarring; they cannot remove scars. The client and the family should be taught the expected cosmetic outcomes. DIF: Applying/Application

N/A TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care) MSC: Integrated Process: Nursing Process (Implementation) 36. An older adult client with burns has a white blood cell count of 10,000/mm3. The client is afebrile with a heart rate of 110 beats/min, a respiratory rate of 20 breaths/min, and blood pressure of 112/68 mm Hg. The clients wound is pale, and edema is noted in the surrounding tissues. Which intervention by the nurse is most appropriate? a. Assess the clients skin for signs of adequate perfusion. b. Calculate intake and output ratio for the last 24 hours. c. Prepare to obtain blood and wound cultures. d. Place the client in an isolation room.

C Older clients have a decreased immune response, so they may not exhibit signs that their immune system is actively fighting an infection such as fever or an increased white blood cell count. They also are at higher risk for sepsis arising from a localized wound infection. The wound shows signs of local infection, so the nurse should assess for this and for systemic infection before the client manifests sepsis. The other options would yield important data but do not take priority over determining whether the client has an infection. DIF: Cognitive Level: Application/Applying or higher

467 KEY: Skin lesions/wounds MSC: Integrated Process: Nursing Process: Assessment NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation 23. After assessing an older adult client with a burn wound, the nurse documents the findings as follows: Vital Signs Laboratory Results Wound Assessment Heart rate: 110 beats/min Blood pressure: 112/68 mm Hg Respiratory rate: 20 breaths/min Oxygen saturation: 94% Pain: 3/10 Red blood cell count: 5,000,000/mm3 White blood cell count: 10,000/mm3 Platelet count: 200,000/mm3 Left chest burn wound, 3 cm 2.5 cm 0.5 cm, wound bed pale, surrounding tissues with edema present Based on the documented data, which action should the nurse take next? a. Assess the clients skin for signs of adequate perfusion. b. Calculate intake and output ratio for the last 24 hours. c. Prepare to obtain blood and wound cultures. d. Place the client in an isolation room.

C Older clients have a decreased immune response, so they may not exhibit signs that their immune system is actively fighting an infection, such as fever or an increased white blood cell count. They also are at higher risk for sepsis arising from a localized wound infection. The burn wound shows signs of local infection, so the nurse should assess for this and for systemic infection before the client manifests sepsis. Placing the client in an isolation room, calculating intake and output, and assessing the clients skin should all be implemented but these actions do not take priority over determining whether the client has an infection. DIF: Analyzing/Analysis

474 KEY: Medical emergency MSC: Integrated Process: Nursing Process: Analysis NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 17. A nurse teaches a client being treated for a full-thickness burn. Which statement should the nurse include in this clients discharge teaching? a. You should change the batteries in your smoke detector once a year. b. Join a program that assists burn clients to reintegration into the community. c. I will demonstrate how to change your wound dressing for you and your family. d. Let me tell you about the many options available to you for reconstructive surgery.

C Teaching clients and family members to perform care tasks such as dressing changes is critical for the progressive goal toward independence for the client. All of the other options are important in the rehabilitation stage. However, dressing changes have priority. DIF: Applying/Application

N/A TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care) MSC: Integrated Process: Teaching/Learning 6. An older client expresses concern about developing new age spots. Which instruction is most important for the nurse to provide to the client? a. Limit the time you spend in the sun. b. Monitor for signs of infection. c. Monitor spots for color change. d. Use skin creams to prevent drying.

C The ABCDE method (check for asymmetry, border irregularity, color variation, diameter, and evolving [changing] in any feature) should be used to assess lesions for signs associated with cancer. Any positive finding using this method requires the lesion to be examined by a dermatologist or a surgeon. The other options are good instructions for clients too, but this client is worried about lesions that are already present. DIF: Cognitive Level: Application/Applying or higher

434 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity 7. The nurse notes the presence of white lesions that resemble milk curds in the back of a patients throat. Which question by the nurse is appropriate at this time? a. Do you have a productive cough? b. How often do you brush your teeth? c. Are you taking any medications at present? d. Have you ever had an oral herpes infection?

C The appearance of the lesions is consistent with an oral candidiasis (thrush) infection, which can occur in patients who are taking medications such as immunosuppressants or antibiotics. Candidiasis is not associated with poor oral hygiene or lower respiratory infections. The lesions do not look like an oral herpes infection. DIF: Cognitive Level: Apply (application)

482 KEY: Hygiene| delegation| skin lesions/wounds| unlicensed assistive personnel (UAP) MSC: Integrated Process: Communication and Documentation NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care 22. A nurse reviews the following data in the chart of a client with burn injuries: Admission Notes Wound Assessment 36-year-old female with bilateral leg burns NKDA Health history of asthma and seasonal allergies Bilateral leg burns present with a white and leather-like appearance. No blisters or bleeding present. Client rates pain 2/10 on a scale of 0-10. Based on the data provided, how should the nurse categorize this clients injuries? a. Partial-thickness deep b. Partial-thickness superficial c. Full thickness d. Superficial

C The characteristics of the clients wounds meet the criteria for a full-thickness injury: color that is black, brown, yellow, white, or red; no blisters; minimal pain; and firm and inelastic outer layer. Partial-thickness superficial burns appear pink to red and are painful. Partial-thickness deep burns are deep red to white and painful. Superficial burns are pink to red and are also painful. DIF: Analyzing/Analysis

N/A TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationMedical Emergencies) MSC: Integrated Process: Nursing Process (Analysis) 11. A client has burns on both legs. These areas appear white and leather-like. No blisters or bleeding is present, and the client describes just a small amount of pain. How does the nurse categorize this injury? a. Partial thickness deep b. Partial thickness superficial c. Full thickness d. Superficial

C The characteristics of the wounds meet the criteria for a full-thickness injury: color that is black, brown, yellow, white, or red; no blisters; minimal pain; and firm and inelastic outer layer. Partial-thickness superficial burns appear pink to red and are painful. Partial-thickness burns are deep red to white and painful, and superficial burns are pink to red and are also painful. DIF: Cognitive Level: Comprehension/Understanding

441 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity 11. A patient is undergoing psoralen plus ultraviolet A light (PUVA) therapy for treatment of psoriasis. What action should the nurse take to prevent adverse effects from this procedure? a. Cleanse the skin carefully with an antiseptic soap. b. Shield any unaffected areas with lead-lined drapes. c. Have the patient use protective eyewear while receiving PUVA. d. Apply petroleum jelly to the areas surrounding the psoriatic lesions.

C The eyes should be shielded from UV light (UVL) during and after PUVA therapy to prevent the development of cataracts. The patient should be taught about the effects of UVL on unaffected skin, but lead-lined drapes, use of antiseptic soap, and petroleum jelly are not used to prevent skin damage. DIF: Cognitive Level: Apply (application)

N/A TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care) MSC: Integrated Process: Nursing Process (Implementation) 7. A client is seen in the clinic for a persistent hand rash. When taking the clients history, the nurse places priority on obtaining information related to which topic? a. Age b. Gender c. Occupation and hobbies d. Socioeconomic status

C The location of the rash suggests contact dermatitis. This condition is most often caused by contact with irritating substances such as might be found in industrial settings or associated with specific hobbies. Socioeconomic status may be related to the rash, particularly if it is associated with poor hygiene, but age and gender are not related to rashes. DIF: Cognitive Level: Application/Applying or higher

N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialDiagnostic Tests) MSC: Integrated Process: Teaching/Learning 3. The nurse observes yellow-tinged sclera on a client with dark skin. Based on this observation, what is the nurses best action? a. Evaluate the client further for hepatitis. b. Examine the soles of the clients feet. c. Inspect the clients oral mucosa. d. Place the client in contact isolation.

C The nurse can best observe jaundice in clients with dark skin by inspecting the oral mucosa, especially the hard palate, for yellow discoloration. Sclera may have subconjunctival fat deposits that show a yellow hue. Before considering hepatitis, the nurse must do a more thorough assessment. The soles of the feet may appear yellow simply from calluses, so this is not the best place to assess. No need to isolate the client has been identified. DIF: Cognitive Level: Application/Applying or higher

421 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 4. When examining an older patient in the home, the home health nurse notices irregular patterns of bruising at different stages of healing on the patients body. Which action should the nurse take first? a. Discourage the use of throw rugs throughout the house. b. Ensure the patient has a pair of shoes with non-slip soles. c. Talk with the patient alone and ask about what caused the bruising. d. Notify the health care provider so that x-rays can be ordered as soon as possible.

C The nurse should note irregular patterns of bruising, especially in the shapes of hands or fingers, in different stages of resolution. These may be indications of other health problems or abuse, and should be further investigated. It is important that the nurse interview the patient alone because, if mistreatment is occurring, the patient may not disclose it in the presence of the person who may be the abuser. Throw rugs and shoes with slippery surfaces may contribute to falls. X-rays may be needed if the patient has fallen recently and also has complaints of pain or decreased mobility. However, the nurses first nursing action is to further assess the patient. DIF: Cognitive Level: Apply (application)

430 TOP: Nursing Process: Implementation MSC: NCLEX: Health Promotion and Maintenance 17. When assessing a new patient at the outpatient clinic, the nurse notes dry, scaly skin; thin hair; and thick, brittle nails. What is the nurses best action? a. Instruct the patient about the importance of nutrition in skin health. b. Make a referral to a podiatrist so that the nails can be safely trimmed. c. Consult with the health care provider about the need for further diagnostic testing. d. Teach the patient about using moisturizing creams and lotions to decrease dry skin.

C The patient has clinical manifestations that could be caused by systemic problems such as malnutrition or hypothyroidism, so further diagnostic evaluation is indicated. Patient teaching about nutrition, addressing the patients dry skin, and referral to a podiatrist may also be needed, but the priority is to rule out underlying disease that may be causing these manifestations. DIF: Cognitive Level: Apply (application)

454 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 2. On admission to the burn unit, a patient with an approximate 25% total body surface area (TBSA) burn has the following initial laboratory results: Hct 58%, Hgb 18.2 mg/dL (172 g/L), serum K+ 4.9 mEq/L (4.8 mmol/L), and serum Na+ 135 mEq/L (135 mmol/L). Which action will the nurse anticipate taking now? a. Monitor urine output every 4 hours. b. Continue to monitor the laboratory results. c. Increase the rate of the ordered IV solution. d. Type and crossmatch for a blood transfusion.

C The patients laboratory data show hemoconcentration, which may lead to a decrease in blood flow to the microcirculation unless fluid intake is increased. Because the hematocrit and hemoglobin are elevated, a transfusion is inappropriate, although transfusions may be needed after the emergent phase once the patients fluid balance has been restored. On admission to a burn unit, the urine output would be monitored more often than every 4 hours; likely every1 hour. DIF: Cognitive Level: Apply (application)

478 KEY: Intravenous fluids| medication MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation 11. A nurse reviews the laboratory results for a client who was burned 24 hours ago. Which laboratory result should the nurse report to the health care provider immediately? a. Arterial pH: 7.32 b. Hematocrit: 52% c. Serum potassium: 6.5 mEq/L d. Serum sodium: 131 mEq/L

C The serum potassium level is changed to the degree that serious life-threatening responses could result. With such a rapid rise in potassium level, the client is at high risk for experiencing severe cardiac dysrhythmias and death. All the other findings are abnormal but do not show the same degree of severity; they would be expected in the emergent phase after a burn injury. DIF: Applying/Application

N/A TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationIllness Management) MSC: Integrated Process: Nursing Process (Implementation) 17. A client is 24 hours post burn and has the following laboratory results. Which result does the nurse report to the health care provider immediately? a. Arterial pH, 7.32 b. Hematocrit, 52% c. Serum potassium,7.5 mEq/L d. Serum sodium, 131 mEq/L

C The serum potassium level is changed to the degree that serious life-threatening responses could result. With such a rapid rise in potassium level, the client is at high risk for experiencing severe cardiac dysrhythmias and death. All the other findings are abnormal but do not show the same degree of severity; they would be expected in the emergent phase after a burn injury. DIF: Cognitive Level: Application/Applying or higher

p. 514 TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationPathophysiology) MSC: Integrated Process: Nursing Process (Assessment) 13. A client with a new burn injury asks the nurse why he is receiving intravenous cimetidine (Tagamet). What is the nurses best response? a. Tagamet will stimulate intestinal movement so you can eat more. b. Tagamet can help prevent hypovolemic shock, which can be fatal. c. This will help prevent stomach ulcers, which are common after burns. d. This drug will help prevent kidney damage caused by dehydration.

C Ulcerative gastrointestinal disease (Curlings ulcer) may develop within 24 hours after a severe burn as a result of increased hydrochloric acid production and a decreased mucosal barrier. This process occurs because of the sympathetic nervous system stress response. Cimetidine inhibits the production and release of hydrochloric acid. Cimetidine does not affect intestinal movement and does not prevent hypovolemic shock or kidney damage. DIF: Cognitive Level: Comprehension/Understanding

474 KEY: Respiratory distress/failure MSC: Integrated Process: Nursing Process: Analysis NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care 8. A nurse prepares to administer intravenous cimetidine (Tagamet) to a client who has a new burn injury. The client asks, Why am I taking this medication? How should the nurse respond? a. Tagamet stimulates intestinal movement so you can eat more. b. It improves fluid retention, which helps prevent hypovolemic shock. c. It helps prevent stomach ulcers, which are common after burns. d. Tagamet protects the kidney from damage caused by dehydration.

C Ulcerative gastrointestinal disease (Curlings ulcer) may develop within 24 hours after a severe burn as a result of increased hydrochloric acid production and a decreased mucosal barrier. This process occurs because of the sympathetic nervous system stress response. Cimetidine is a histamine2 blocker and inhibits the production and release of hydrochloric acid. Cimetidine does not affect intestinal movement and does not prevent hypovolemic shock or kidney damage. DIF: Applying/Application

460 KEY: Skin lesions/wounds MSC: Integrated Process: Nursing Process: Assessment NOT: Client Needs Category: Health Promotion and Maintenance 15. A nurse cares for a client who is prescribed vancomycin (Vancocin) 500 mg IV every 6 hours for a methicillin-resistant Staphylococcus aureus (MRSA) infection. Which action should the nurse take? a. Administer it over 30 minutes using an IV pump. b. Give the client diphenhydramine (Benadryl) before the drug. c. Assess the IV site at least every 2 hours for thrombophlebitis. d. Ensure that the client has increased oral intake during therapy.

C Vancomycin is very irritating to the veins and can easily cause thrombophlebitis. This drug is given over at least 60 minutes; although it can cause histamine release (leading to red man syndrome), it is not customary to administer diphenhydramine before starting the infusion. Increasing oral intake is not specific to vancomycin therapy. DIF: Applying/Application

430-431 | 433 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity 13. Which information will the nurse include when teaching an older patient about skin care? a. Dry the skin thoroughly before applying lotions. b. Bathe and wash hair daily with soap and shampoo. c. Use warm water and a moisturizing soap when bathing. d. Use antibacterial soaps when bathing to avoid infection.

C Warm water and moisturizing soap will avoid overdrying the skin. Because older patients have dryer skin, daily bathing and shampooing are not necessary and may dry the skin unnecessarily. Antibacterial soaps are not necessary. Lotions should be applied while the skin is still damp to seal moisture in. DIF: Cognitive Level: Apply (application)

425 KEY: Vascular perfusion MSC: Integrated Process: Nursing Process: Assessment NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care 7. A nurse cares for an older adult client who has a chronic skin disorder. The client states, I have not been to church in several weeks because of the discoloration of my skin. How should the nurse respond? a. I will consult the chaplain to provide you with spiritual support. b. You do not need to go to church; God is everywhere. c. Tell me more about your concerns related to your skin. d. Religious people are nonjudgmental and will accept you.

C Clients with chronic skin disorders often become socially isolated related to the fear of rejection by others. Nurses should assess how the clients skin changes are affecting the clients body image and encourage the client to express his or her feelings about a change in appearance. The other responses are not appropriate. DIF: Applying/Application

424 KEY: Medications| adverse effects MSC: Integrated Process: Nursing Process: Assessment NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 4. After teaching a client who expressed concern about a rash located beneath her breast, a nurse assesses the clients understanding. Which statement indicates the client has a good understanding of this condition? a. This rash is probably due to fluid overload. b. I need to wash this daily with antibacterial soap. c. I can use powder to keep this area dry. d. I will schedule a mammogram as soon as I can.

C Rashes limited to skinfold areas (e.g., on the axillae, beneath the breasts, in the groin) may reflect problems related to excessive moisture. The client needs to keep the area dry; one option is to use powder. Good hygiene is important, but the rash does not need an antibacterial soap. Fluid overload and breast cancer are not related to rashes in skinfolds. DIF: Applying/Application

446 KEY: Skin lesions/wounds MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation 5. A nurse is caring for a client who has a pressure ulcer on the right ankle. Which action should the nurse take first? a. Draw blood for albumin, prealbumin, and total protein. b. Prepare for and assist with obtaining a wound culture. c. Place the client in bed and instruct the client to elevate the foot. d. Assess the right leg for pulses, skin color, and temperature.

D A client with an ulcer on the foot should be assessed for interruption in arterial flow to the area. This begins with the assessment of pulses and color and temperature of the skin. The nurse can also assess for pulses noninvasively with a Doppler flowmeter if unable to palpate with his or her fingers. Tests to determine nutritional status and risk assessment would be completed after the initial assessment is done. Wound cultures are done after it has been determined that drainage, odor, and other risks for infection are present. Elevation of the foot would impair the ability of arterial blood to flow to the area. DIF: Applying/Application

455 | 457 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 17. A patient who has burns on the arms, legs, and chest from a house fire has become agitated and restless 8 hours after being admitted to the hospital. Which action should the nurse take first? a. Stay at the bedside and reassure the patient. b. Administer the ordered morphine sulfate IV. c. Assess orientation and level of consciousness. d. Use pulse oximetry to check the oxygen saturation.

D Agitation in a patient who may have suffered inhalation injury might indicate hypoxia, and this should be assessed by the nurse first. Administration of morphine may be indicated if the nurse determines that the agitation is caused by pain. Assessing level of consciousness and orientation is also appropriate but not as essential as determining whether the patient is hypoxemic. Reassurance is not helpful to reduce agitation in a hypoxemic patient. DIF: Cognitive Level: Apply (application)

N/A TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationIllness Management) MSC: Integrated Process: Nursing Process (Analysis) 25. The nurse provides wound care for a client 48 hours after a burn injury. To achieve the desired outcome of the procedure, which action does the nurse perform first? a. Apply silver sulfadiazine (Silvadene) ointment. b. Cover the area with an elastic wrap. c. Place a synthetic dressing over the area. d. Remove loose nonviable tissue.

D All steps are part of the nonsurgical wound care for clients with burn injuries. The first step in this process consists of removing exudates and necrotic tissue. This promotes wound healing. DIF: Cognitive Level: Application/Applying or higher

440 TOP: Nursing Process: Implementation MSC: NCLEX: Health Promotion and Maintenance 18. An older adult patient with a squamous cell carcinoma (SCC) on the lower arm has a Mohs procedure in the dermatology clinic. Which nursing action will be included in the postoperative plan of care? a. Describe the use of topical fluorouracil on the incision. b. Teach how to use sterile technique to clean the suture line. c. Schedule daily appointments for wet-to-dry dressing changes. d. Teach about the use of cold packs to reduce bruising and swelling.

D Application of cold packs to the incision after the surgery will help decrease bruising and swelling at the site. Since the Mohs procedure results in complete excision of the lesion, topical fluorouracil is not needed after surgery. After the Mohs procedure the edges of the wound can be left open to heal or the edges can be approximated and sutured together. The suture line can be cleaned with tap water. No debridement with wet-to-dry dressings is indicated. DIF: Cognitive Level: Apply (application)

452 | 456 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 27. Which action will the nurse include in the plan of care for a patient in the rehabilitation phase after a burn injury to the right arm and chest? a. Keep the right arm in a position of comfort. b. Avoid the use of sustained-release narcotics. c. Teach about the purpose of tetanus immunization. d. Apply water-based cream to burned areas frequently.

D Application of water-based emollients will moisturize new skin and decrease flakiness and itching. To avoid contractures, the joints of the right arm should be positioned in an extended position, which is not the position of comfort. Patients may need to continue the use of opioids during rehabilitation. Tetanus immunization would have been given during the emergent phase of the burn injury. DIF: Cognitive Level: Apply (application)

429 TOP: Nursing Process: Implementation MSC: NCLEX: Health Promotion and Maintenance 3. A nurse develops a teaching plan for a patient diagnosed with basal cell carcinoma (BCC). Which information should the nurse include in the teaching plan? a. Treatment plans include watchful waiting. b. Screening for metastasis will be important. c. Low dose systemic chemotherapy is used to treat BCC. d. Minimizing sun exposure will reduce risk for future BCC.

D BCC is frequently associated with sun exposure and preventive measures should be taken for future sun exposure. BCC spreads locally, and does not metastasize to distant tissues. Since BCC can cause local tissue destruction, treatment is indicated. Local (not systemic) chemotherapy may be used to treat BCC. DIF: Cognitive Level: Apply (application)

431-432 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity 5. A patient has the following risk factors for melanoma. Which risk factor should the nurse assign as the priority focus of patient teaching? a. The patient has multiple dysplastic nevi. b. The patient is fair-skinned and has blue eyes. c. The patients mother died of a malignant melanoma. d. The patient uses a tanning booth throughout the winter.

D Because the only risk factor that the patient can change is the use of a tanning booth, the nurse should focus teaching about melanoma prevention on this factor. The other factors also will contribute to increased risk for melanoma. DIF: Cognitive Level: Apply (application)

430 TOP: Nursing Process: Implementation MSC: NCLEX: Health Promotion and Maintenance 14. What is the best method to prevent the spread of infection when the nurse is changing the dressing over a wound infected with Staphylococcus aureus? a. Change the dressing using sterile gloves. b. Soak the dressing in sterile normal saline. c. Apply antibiotic ointment over the wound. d. Wash hands and properly dispose of soiled dressings.

D Careful hand washing and the safe disposal of soiled dressings are the best means of preventing the spread of skin problems. Sterile glove and sterile saline use during wound care will not necessarily prevent spread of infection. Applying antibiotic ointment will treat the bacteria but not necessarily prevent the spread of infection. DIF: Cognitive Level: Apply (application)

N/A TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationPathophysiology) MSC: Integrated Process: Nursing Process (Analysis) 9. A client has multiple bruises on the arms. Which question provides the nurse with the most information? a. Are you using lotion on your skin? b. Do you have a family history of this? c. Do your arms itch? d. What medication are you taking?

D Certain drugs such as aspirin, warfarin, and corticosteroids can lead to easy or excessive bruising, which can result in ecchymosis. The other options would not provide information about bruising. DIF: Cognitive Level: Application/Applying or higher

443 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity 21. The nurse is caring for a patient diagnosed with furunculosis. Which nursing action could the nurse delegate to unlicensed assistive personnel (UAP)? a. Applying antibiotic cream to the groin. b. Obtaining cultures from ruptured lesions. c. Evaluating the patients personal hygiene. d. Cleaning the skin with antimicrobial soap.

D Cleaning the skin is within the education and scope of practice for UAP. Administration of medication, obtaining cultures, and evaluation are higher-level skills that require the education and scope of practice of licensed nursing personnel. DIF: Cognitive Level: Apply (application)

451 KEY: Transmission-Based Precautions| infection MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control 10. After teaching a client how to care for a furuncle in the axilla, a nurse assesses the clients understanding. Which statement indicates the client correctly understands the teaching? a. Ill apply cortisone cream to reduce the inflammation. b. Ill apply a clean dressing after squeezing out the pus. c. Ill keep my arm down at my side to prevent spread. d. Ill cleanse the area prior to applying antibiotic cream.

D Cleansing and topical antibiotics can eliminate the infection. Warm compresses enhance comfort and open the lesion, allowing better penetration of the topical antibiotic. Cortisone cream reduces the inflammatory response but increases the infectious process. Squeezing the lesion may introduce infection to deeper tissues and cause cellulitis. Keeping the arm down increases moisture in the area and promotes bacterial growth. DIF: Applying/Application

N/A TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationMedical Emergencies) MSC: Integrated Process: Nursing Process (Implementation) 15. On assessment, the nurse notes that a client has burns inside the mouth and is wheezing. Several hours later, the wheezing is no longer heard. What is the nurses next action? a. Document the findings and reassess in 1 hour. b. Loosen any constrictive dressings on the chest. c. Raise the head of the bed to a semi-Fowlers position. d. Gather appropriate equipment and prepare for intubation.

D Clients with severe inhalation injuries may sustain such progressive obstruction that they may lose effective movement of air. When this occurs, wheezing is no longer heard, and neither are breath sounds. These clients can lose their airways very quickly, so prompt action is needed. The client requires establishment of an emergency airway. Swelling usually precludes intubation. DIF: Cognitive Level: Application/Applying or higher

489 KEY: Skin lesions/wounds MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Health Promotion and Maintenance 18. A nurse assesses bilateral wheezes in a client with burn injuries inside the mouth. Four hours later the wheezing is no longer heard. Which action should the nurse take? a. Document the findings and reassess in 1 hour. b. Loosen any constrictive dressings on the chest. c. Raise the head of the bed to a semi-Fowlers position. d. Gather appropriate equipment and prepare for an emergency airway.

D Clients with severe inhalation injuries may sustain such progressive obstruction that they may lose effective movement of air. When this occurs, wheezing is no longer heard, and neither are breath sounds. These clients can lose their airways very quickly, so prompt action is needed. The client requires establishment of an emergency airway. Swelling usually precludes intubation. The other options do not address this emergency situation. DIF: Applying/Application

N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialSystem-Specific Assessments) MSC: Integrated Process: Nursing Process (Assessment) 5. An older client with age spots is fearful of contracting skin cancer but wants to continue his hobby of outdoor gardening. Which statement by the client indicates a good understanding of the teaching about this issue? a. I will avoid staying outside during the day. b. I can use only oil-based tanning lotion. c. I have to start growing plants indoors. d. I will wear a hat and gloves when gardening.

D Freckles, birthmarks, and age spots are caused by patches of melanin in the skin. Melanin protects against the harmful effects of sun exposure. Hyperpigmentation can occur in sun-exposed areas and can lead to skin cancer. For clients who spend time outdoors, the best protection from skin cancer is decreasing the amount of skin exposed to sunlight. DIF: Cognitive Level: Application/Applying or higher

458 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 10. Esomeprazole (Nexium) is prescribed for a patient who incurred extensive burn injuries 5 days ago. Which nursing assessment would best evaluate the effectiveness of the medication? a. Bowel sounds b. Stool frequency c. Abdominal distention d. Stools for occult blood

D H2 blockers and proton pump inhibitors are given to prevent Curlings ulcer in the patient who has suffered burn injuries. Proton pump inhibitors usually do not affect bowel sounds, stool frequency, or appetite. DIF: Cognitive Level: Apply (application)

456 KEY: Skin lesions/wounds| nonpharmacologic pain management MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Physiological Integrity: Basic Care and Comfort 1. The registered nurse assigns a client who has an open burn wound to a licensed practical nurse (LPN). Which instruction should the nurse provide to the LPN when assigning this client? a. Administer the prescribed tetanus toxoid vaccine. b. Assess the clients wounds for signs of infection. c. Encourage the client to breathe deeply every hour. d. Wash your hands on entering the clients room.

D Infection can occur when microorganisms from another person or from the environment are transferred to the client. Although all of the interventions listed can help reduce the risk for infection, handwashing is the most effective technique for preventing infection transmission. DIF: Applying/Application

N/A TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationAlterations in Body Systems) MSC: Integrated Process: Nursing Process (Implementation) 1. The RN has assigned a client who has an open burn wound to the LPN. Which instruction is most important for the RN to provide the LPN? a. Administer the prescribed tetanus toxoid vaccine. b. Assess wounds for signs of infection. c. Have the client cough and breathe deeply. d. Wash hands on entering the clients room.

D Infection can occur when microorganisms from another person or from the environment are transferred to the client. Although all of the interventions listed can help reduce the risk for infection, handwashing is the most effective technique for preventing infection transmission. DIF: Cognitive Level: Application/Applying or higher

N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for Complications from Surgical Procedures and Health Alterations) MSC: Integrated Process: Nursing Process (Implementation) 27. The family of a client who has been burned asks when the client will no longer be at greater risk for infection. What is the nurses best response? a. As soon as the antibiotics have been finished. b. As soon as albumin levels returns to normal. c. When fluid remobilization has started. d. When the burn wounds are closed.

D Intact skin is a major barrier to infection and other disruptions in homeostasis. No matter how much time has passed since the burn injury, the client remains at high risk for infection as long as any area of skin is open. DIF: Cognitive Level: Comprehension/Understanding

475 KEY: Respiratory distress/failure MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care 13. A nurse cares for a client who has burn injuries. The clients wife asks, When will his high risk for infection decrease? How should the nurse respond? a. When the antibiotic therapy is complete. b. As soon as his albumin levels return to normal. c. Once we complete the fluid resuscitation process. d. When all of his burn wounds have closed.

D Intact skin is a major barrier to infection and other disruptions in homeostasis. No matter how much time has passed since the burn injury, the client remains at high risk for infection as long as any area of skin is open. Although the other options are important goals in the clients recovery process, they are not as important as skin closure to decrease the clients risk for infection. DIF: Understanding/Comprehension

457 KEY: Medication administration MSC: Integrated Process: Nursing Process: Assessment NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 17. A nurse cares for clients who have various skin infections. Which infection is paired with the correct pharmacologic treatment? a. Viral infection Clindamycin (Cleocin) b. Bacterial infection Acyclovir (Zovirax) c. Yeast infection Linezolid (Zyvox) d. Fungal infection Ketoconazole (Nizoral)

D Ketoconazole is an antifungal. Clindamycin and linezolid are antibiotics. Acyclovir is an antiviral drug. DIF: Remembering/Knowledge

465 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity 11. The nurse is reviewing the medication administration record (MAR) on a patient with partial-thickness burns. Which medication is best for the nurse to administer before scheduled wound debridement? a. Ketorolac (Toradol) b. Lorazepam (Ativan) c. Gabapentin (Neurontin) d. Hydromorphone (Dilaudid)

D Opioid pain medications are the best choice for pain control. The other medications are used as adjuvants to enhance the effects of opioids. DIF: Cognitive Level: Apply (application)

446 OBJ: Special Questions: Delegation TOP: Nursing Process: Planning MSC: NCLEX: Safe and Effective Care Environment 22. The nurse assesses a patient who has just arrived in the postanesthesia recovery area (PACU) after a blepharoplasty. Which assessment data should be reported to the surgeon immediately? a. The patient complains of incisional pain. b. The patients heart rate is 110 beats/minute. c. The patient is unable to detect when the eyelids are touched. d. The skin around the incision is pale and cold when palpated.

D Pale, cool skin indicates a possible decrease in circulation, so the surgeon should be notified immediately. The other assessment data indicate a need for ongoing assessment or nursing action. A heart rate of 110 beats/minute may be related to the stress associated with surgery. Assessment of other vital signs and continued monitoring are appropriate. Because local anesthesia would be used for the procedure, numbness of the incisional area is expected immediately after surgery. The nurse should monitor for return of feeling. DIF: Cognitive Level: Apply (application)

422 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 11. Which abnormality on the skin of an older patient is the priority to discuss immediately with the health care provider? a. Several dry, scaly patches on the face b. Numerous varicosities noted on both legs c. Dilation of small blood vessels on the face d. Petechiae present on the chest and abdomen

D Petechiae are caused by pinpoint hemorrhages and are associated with a variety of serious disorders such as meningitis and coagulopathies. The nurse should contact the patients health care provider about this finding for further diagnostic follow-up. The other skin changes are associated with aging. Although the other changes will also require ongoing monitoring or intervention by the nurse, they do not indicate a need for urgent action. DIF: Cognitive Level: Apply (application)

477 KEY: Electrolyte imbalance MSC: Integrated Process: Nursing Process: Analysis NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation 12. A nurse assesses a client who has burn injuries and notes crackles in bilateral lung bases, a respiratory rate of 40 breaths/min, and a productive cough with blood-tinged sputum. Which action should the nurse take next? a. Administer furosemide (Lasix). b. Perform chest physiotherapy. c. Document and reassess in an hour. d. Place the client in an upright position.

D Pulmonary edema can result from fluid resuscitation given for burn treatment. This can occur even in a young healthy person. Placing the client in an upright position can relieve lung congestion immediately before other measures can be carried out. Although Lasix may be used to treat pulmonary edema in clients who are fluid overloaded, a client with a burn injury will lose a significant amount of fluid through the broken skin; therefore, Lasix would not be appropriate. Chest physiotherapy will not get rid of fluid. DIF: Applying/Application

N/A TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationPathophysiology) MSC: Integrated Process: Nursing Process (Implementation) 19. A client who was burned has crackles in both lung bases and a respiratory rate of 40 breaths/min and is coughing up blood-tinged sputum. Which action by the nurse takes priority? a. Administer digoxin. b. Perform chest physiotherapy. c. Document and reassess in an hour. d. Place the client in an upright position.

D Pulmonary edema can result from fluid resuscitation given for burn treatment. This can occur even in a young healthy person. Placing the client in an upright position can relieve lung congestion immediately before other measures can be carried out. Digoxin may be given later to enhance cardiac contractility to prevent backup of fluid into the lungs. Chest physiotherapy will not get rid of fluid. DIF: Cognitive Level: Application/Applying or higher

N/A TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care) MSC: Integrated Process: Teaching/Learning 11. A client asks the nurse if a Woods light examination is painful. Which response by the nurse is accurate? a. A local anesthetic will be used to prevent pain. b. The pain lasts only a few seconds. c. Some clients feel a pressure-like sensation. d. The examination does not cause discomfort.

D The Woods light examination consists of use of a black light and a darkened room to assist with physical examination of the skin. The examination does not cause discomfort. DIF: Cognitive Level: Comprehension/Understanding

421 KEY: Skin lesions/wounds MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Health Promotion and Maintenance 1. A nurse teaches a client who has very dry skin. Which statement should the nurse include in this clients education? a. Use lots of moisturizer several times a day to minimize dryness. b. Take a cold shower instead of soaking in the bathtub. c. Use antimicrobial soap to avoid infection of cracked skin. d. After you bathe, put lotion on before your skin is totally dry.

D The client should bathe in warm water for at least 20 minutes and then apply lotion immediately because this will keep the moisture in the skin. Just using moisturizer will not be as helpful because the moisturizer is not what rehydrates the skin; it is the water. Bathing in warm water will rehydrate skin more effectively than a cold shower, and antimicrobial soaps are actually more drying than other kinds of soap. DIF: Applying/Application

425 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity 9. During assessment of the patients skin, the nurse observes a similar pattern of small, raised lesions on the left and right upper back areas. Which term should the nurse use to document these lesions? a. Confluent b. Zosteriform c. Generalized d. Symmetric

D The description of the lesions indicates that they are grouped. The other terms are inconsistent with the description of the lesions. DIF: Cognitive Level: Understand (comprehension)

440 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 12. A patient with an enlarging, irregular mole that is 7 mm in diameter is scheduled for outpatient treatment. The nurse should plan to prepare the patient for which procedure? a. Curettage b. Cryosurgery c. Punch biopsy d. Surgical excision

D The description of the mole is consistent with malignancy, so excision and biopsy are indicated. Curettage and cryosurgery are not used if malignancy is suspected. A punch biopsy would not be done for a lesion greater than 5 mm in diameter. DIF: Cognitive Level: Apply (application)

N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for Alterations in Body Systems) MSC: Integrated Process: Nursing Process (Assessment) 24. A client is receiving fluid resuscitation after a burn. Which finding indicates that fluid resuscitation is adequate for this client? a. Hematocrit = 60% b. Heart rate = 130 beats/min c. Increased peripheral edema d. Urine output = 50 mL/hr

D The fluid remobilization phase improves renal blood flow, increases diuresis, and restores blood pressure and heart rate, as well as laboratory values, to more normal levels. DIF: Cognitive Level: Application/Applying or higher

446 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 23. A patient who has severe refractory psoriasis on the face, neck, and extremities is socially withdrawn because of the appearance of the lesions. Which action should the nurse take first? a. Discuss the possibility of enrolling in a worker-retraining program. b. Encourage the patient to volunteer to work on community projects. c. Suggest that the patient use cosmetics to cover the psoriatic lesions. d. Ask the patient to describe the impact of psoriasis on quality of life.

D The nurses initial actions should be to assess the impact of the disease on the patients life and to allow the patient to verbalize feelings about the psoriasis. Depending on the assessment findings, other actions may be appropriate. DIF: Cognitive Level: Apply (application)

444 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 19. A patient with atopic dermatitis has a new prescription for pimecrolimus (Elidel). After teaching the patient about the medication, which statement by the patient indicates that further teaching is needed? a. After I apply the medication, I can go ahead and get dressed as usual. b. I will need to minimize my time in the sun while I am using the Elidel. c. I will rub the medication gently onto the skin every morning and night. d. If the medication burns when I apply it, I will wipe it off and call the doctor.

D The patient should be taught that transient burning at the application site is an expected effect of pimecrolimus and that the medication should be left in place. The other statements by the patient are accurate and indicate that patient teaching has been effective. DIF: Cognitive Level: Apply (application)

15-16 OBJ: Special Questions: Delegation TOP: Nursing Process: Planning MSC: NCLEX: Safe and Effective Care Environment 23. A patient who was found unconscious in a burning house is brought to the emergency department by ambulance. The nurse notes that the patients skin color is bright red. Which action should the nurse take first? a. Insert two large-bore IV lines. b. Check the patients orientation. c. Assess for singed nasal hair and dark oral mucous membranes. d. Place the patient on 100% oxygen using a non-rebreather mask.

D The patients history and skin color suggest carbon monoxide poisoning, which should be treated by rapidly starting oxygen at 100%. The other actions can be taken after the action to correct gas exchange. DIF: Cognitive Level: Apply (application)

441 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 16. The nurse notes darker skin pigmentation in the skinfolds of a middle-aged patient who has a body mass index of 40 kg/m2. What is the nurses best action? a. Teach the patient about the treatment of fungal infection. b. Discuss the use of drying agents to minimize infection risk. c. Instruct the patient about the use of mild soap to clean skinfolds. d. Ask the patient about type 2 diabetes or if there is a family history of it.

D The presence of acanthosis nigricans in skinfolds suggests either having type 2 diabetes or being at an increased risk for it. The description of the patients skin does not indicate problems with fungal infection, poor hygiene, or the need to dry the skinfolds better. DIF: Cognitive Level: Apply (application)

15-16 OBJ: Special Questions: Delegation TOP: Nursing Process: Planning MSC: NCLEX: Safe and Effective Care Environmen 1. Which information should the nurse include when teaching patients about decreasing the risk for sun damage to the skin? a. Use a sunscreen with an SPF of at least 8 to 10 for adequate protection. b. Water resistant sunscreens will provide good protection when swimming. c. Increase sun exposure by no more than 10 minutes a day to avoid skin damage. d. Try to stay out of the sun between the hours of 10 AM and 2 PM (regular time).

D The risk for skin damage from the sun is highest with exposure between 10 AM and 2 PM. No sunscreen is completely water resistant. Sunscreens classified as water resistant sunscreens still need to be reapplied after swimming. Sunscreen with an SPF of at least 15 is recommended for people at normal risk for skin cancer. Although gradually increasing sun exposure may decrease the risk for burning, the risk for skin cancer is not decreased. DIF: Cognitive Level: Apply (application)

452 | 456 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 20. Eight hours after a thermal burn covering 50% of a patients total body surface area (TBSA) the nurse assesses the patient. Which information would be a priority to communicate to the health care provider? a. Blood pressure is 95/48 per arterial line. b. Serous exudate is leaking from the burns. c. Cardiac monitor shows a pulse rate of 108. d. Urine output is 20 mL per hour for the past 2 hours.

D The urine output should be at least 0.5 to 1.0 mL/kg/hr during the emergent phase, when the patient is at great risk for hypovolemic shock. The nurse should notify the health care provider because a higher IV fluid rate is needed. BP during the emergent phase should be greater than 90 systolic, and the pulse rate should be less than 120. Serous exudate from the burns is expected during the emergent phase. DIF: Cognitive Level: Apply (application)

467 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 12. A young adult patient who is in the rehabilitation phase after having deep partial-thickness face and neck burns has a nursing diagnosis of disturbed body image. Which statement by the patient indicates that the problem is resolving? a. Im glad the scars are only temporary. b. I will avoid using a pillow, so my neck will be OK. c. I bet my boyfriend wont even want to look at me anymore. d. Do you think dark beige makeup foundation would cover this scar on my cheek?

D The willingness to use strategies to enhance appearance is an indication that the disturbed body image is resolving. Expressing feelings about the scars indicates a willingness to discuss appearance, but not resolution of the problem. Because deep partial-thickness burns leave permanent scars, a statement that the scars are temporary indicates denial rather than resolution of the problem. Avoiding using a pillow will help prevent contractures, but it does not address the problem of disturbed body image. DIF: Cognitive Level: Apply (application)

p. 512 TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for Alterations in Body Systems) MSC: Integrated Process: Teaching/Learning 28. A client with open burn wounds begins to have diarrhea. The client is found to have a below-normal temperature, with a white blood cell count of 4000/mm3. Which action by the nurse is most appropriate? a. Continue to monitor the client. b. Increase the temperature in the room. c. Increase the rate of intravenous fluids. d. Prepare to do a workup for sepsis.

D These findings are associated with systemic Gram-negative infection and sepsis. To verify that sepsis is occurring, cultures of the wound and blood must be taken to determine the appropriate antibiotic to be started. Continuing just to monitor the situation can lead to septic shock. Increasing the temperature in the room may make the client more comfortable, but the priority is finding out whether the client has sepsis and treating it before it becomes a shock situation. The rate of intravenous fluids may be increased to replace fluid losses associated with diarrhea, but this is not the priority action. DIF: Cognitive Level: Application/Applying or higher

N/A TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral TherapiesAdverse Effects/Contraindications/Side Effects/Interactions) MSC: Integrated Process: Nursing Process (Assessment) 10. A client had an excisional biopsy on a neck lesion. Which information does the nurse include in the discharge instructions? a. Stay in bed today to prevent excessive bleeding from the incision. b. Do not drive until you have recovered from the anesthesia. c. You will need to change the dressing daily for a week. d. Keep the dressing on until tomorrow, then you may remove it.

D This client has no reason to avoid going about normal activities as long as the site stays covered for a day with a dressing. Movement should not cause excessive bleeding, and general anesthesia would not have been used. DIF: Cognitive Level: Application/Applying or higher

437 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 9. The health care provider prescribes topical 5-FU for a patient with actinic keratosis on the left cheek. The nurse should include which statement in the patients instructions? a. 5-FU will shrink the lesion so that less scarring occurs once the lesion is excised. b. You may develop nausea and anorexia, but good nutrition is important during treatment. c. You will need to avoid crowds because of the risk for infection caused by chemotherapy. d. Your cheek area will be painful and develop eroded areas that will take weeks to heal.

D Topical 5-FU causes an initial reaction of erythema, itching, and erosion that lasts 4 weeks after application of the medication is stopped. The medication is topical, so there are no systemic effects such as increased infection risk, anorexia, or nausea. DIF: Cognitive Level: Apply (application)

460 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 5. During the emergent phase of burn care, which assessment will be most useful in determining whether the patient is receiving adequate fluid infusion? a. Check skin turgor. b. Monitor daily weight. c. Assess mucous membranes. d. Measure hourly urine output.

D When fluid intake is adequate, the urine output will be at least 0.5 to 1 mL/kg/hour. The patients weight is not useful in this situation because of the effects of third spacing and evaporative fluid loss. Mucous membrane assessment and skin turgor also may be used, but they are not as adequate in determining that fluid infusions are maintaining adequate perfusion. DIF: Cognitive Level: Apply (application)

427 KEY: Infection MSC: Integrated Process: Nursing Process: Analysis NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care 3. A nurse assesses a client who has multiple areas of ecchymosis on both arms. Which question should the nurse ask first? a. Are you using lotion on your skin? b. Do you have a family history of this? c. Do your arms itch? d. What medications are you taking?

D Certain drugs such as aspirin, warfarin, and corticosteroids can lead to easy or excessive bruising, which can result in ecchymosis. The other options would not provide information about bruising. DIF: Applying/Application

417 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity MULTIPLE RESPONSE 1. When taking the health history of an older adult, the nurse discovers that the patient has worked in the landscaping business for 40 years. The nurse will plan to teach the patient about how to self-assess for which clinical manifestations (select all that apply)? a. Vitiligo b. Alopecia c. Intertrigo d. Erythema e. Actinic keratosis

D, E A patient who has worked as a landscaper is at risk for skin lesions caused by sun exposure such as erythema and actinic keratosis. Vitiligo, alopecia, and intertrigo are not associated with excessive sun exposure. DIF: Cognitive Level: Analyze (analysis)

454 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity OTHER 1. In which order will the nurse take these actions when doing a dressing change for a partial-thickness burn wound on a patients chest? (Put a comma and a space between each answer choice [A, B, C, D, E].) a. Apply sterile gauze dressing. b. Document wound appearance. c. Apply silver sulfadiazine cream. d. Administer IV fentanyl (Sublimaze). e. Clean wound with saline-soaked gauze.

D, E, C, A, B Because partial-thickness burns are very painful, the nurses first action should be to administer pain medications. The wound will then be cleaned, antibacterial cream applied, and covered with a new sterile dressing. The last action should be to document the appearance of the wound. DIF: Cognitive Level: Apply (application)

N/A TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationAlterations in Body Systems) MSC: Integrated Process: Nursing Process (Assessment) MULTIPLE RESPONSE 1. The nurse is assessing for skin changes in an older woman. Which findings require immediate referral? (Select all that apply.) a. Excessive moisture under axilla b. Increased hair thinning c. Increased presence of fungal toenails d. Lesion with various colors e. Spider veins on legs f. Asymmetric 6-mm dark lesion on forehead

D, F The asymmetric 6-mm dark lesion, as well as the lesion with various colors, fits two of the American Cancer Societys hallmark signs for cancer according to the ABCD method. Other manifestations are variants of normal seen in various age-groups. DIF: Cognitive Level: Application/Applying or higher

422 KEY: Skin lesions/wounds| documentation MSC: Integrated Process: Communication and Documentation NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation MULTIPLE RESPONSE 1. A nurse assesses an older adults skin. Which findings require immediate referral? (Select all that apply.) a. Excessive moisture under axilla b. Increased hair thinning c. Increased presence of fungal toenails d. Lesion with various colors e. Spider veins on legs f. Asymmetric 6-mm dark lesion on forehead

D, F The lesion with various colors, as well as the asymmetric 6-mm dark lesion, fits two of the American Cancer Societys hallmark signs for cancer according to the ABCD method. Other manifestations are variants of normal seen in various age groups. DIF: Applying/Application