NCLEX-ADULT

The nurse reinforces instructions to a group of clients regarding measures that will assist with the prevention of skin cancer. Which statement by a client indicates the need for further teaching?

"I need to avoid sun exposure before 10:00 am and after 4:00 pm."

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

36%

A client arrives at the emergency department and has experienced forstbite to the right hand. What should the nurse expect to find when inspecting the client's hand?

A white color of the skin which is insensitive to touch

The nurse, employed in a long-term care facility, is planning the clinical assignments for the day. The nurse knows not to assign which staff member to the client with a diagnosis of herpes zoster?

An unlicensed assistive personnel who has never had chickenpox

The nurse is caring for a client with circumferential burns of both legs. Which leg position is appropriate for this type of a burn?

Elevation above the level of the heart

A client returns to the clinic for follow-up treatment after a skin biopsy of a suspicious lesion that was performed 1 week ago. The biopsy report indicates that the lesion is a melanoma. The nurse understands that which characteristics describe this type of a lesion? Select all that apply

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

The nurse is reviewing the health care record of a client which a lesion that has been diagnosed as basal cell carcinoma. The nurse should expect which characteristics of this type of lesion to be documented in the client's record? Select all that apply

Lesion has a waxy border An irregularly shaped lesion

The evening nurse reviews the nursing documentation in the client's chart and notes that the day nurse had documented that the client has a stage 2 pressure injury in the sacral area. What should the nurse expect to find when checking the client's sacral area?

Partial-thickness skin loss of the epidermis

The nurse is assigned to care for a client with herpes zoster. Based on an understanding of the cause of this disorder, the nurse determines that this definitive diagnosis was made by which diagnosis test?

Positive culture results

The nurse inspects the skin of a client who is suspected of having psoriasis. Which finding should the nurse note if this disorder is present?

Silvery-white scaly lesions

The nurse is caring for a client who has just been admitted tot he nursing unite after receiving flame burns to the face and chest. the nurse notes a hoarse cough, and the client is expectorating sputum with black flecks. The client suddenly becomes restless and his color is becoming dusky. Based on this data, which interpretation should the nurse make?

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

The nurse is told that an assigned client is suspected of having methicillin-resistant Staphylococcus aureus (MRSA). Which precautions should the nurse institute during the care of the client?

Wear a gown and gloves

The client arrives at the emergency department after a burn injury that occurred in their home basement and an inhalation injury is suspected. Which should the nurse anticipate as being prescribed for the client?

100% oxygen via a tight-fitting nonrebreather face mask

Which should be the anticipated therapeutic outcome of an escharotomy procedure performed for a circumferential arm burn?

The return of distal pulses

The nurse is assisting with caring for a client who is receiving intravenous fluids and who has sustained full-thickness burn injuries of the back and legs. The nurse understands that which would provide the most reliable indicator for determining the adequacy of the fluid resuscitation?

Urine output