EXAM 5

Burns- Rule of 9 question- the front torso, & both legs=54 (18+18+18)

The nurse is reinforcing health teaching about skin cancer with a group of clients. Which
of the following risk factors does the nurse identify as the leading cause of non-
melanoma skin cancer?

● Sun exposure.

A charge nurse is observing a staff member caring for a client who has multiple skin
lesions from a varicella zoster infection. Which of the following actions should the
charge nurse identify as an indication that the nurse understands the precautions to take
when caring for a client who has this infection?

● The nurse wears a high-efficiency particulate air (HEPA) filter mask.

A nurse has collected data from a client who reported findings of new skin lesions.
Which of the following actions is the nurse's priority?

● We identify when the client first noticed the lesion.

The nurse is reinforcing the client who has a skin lesion and is scheduled for excisional
skin biopsy. Which of the following information should the nurse include in the
teaching?

● "You will need to change the dressing daily."

A nurse has collected data from an older adult client who comes to the clinic with dry,
flaky skin on the upper back. Which of the following actions should the nurse take?

● Check for skin turgor.

A nurse is assisting in planning an educational session regarding risk factors for skin
cancer. Which of the following information should the nurse plan to include in the
session?

● We're going to educate about overexposure to UV light, chronic skin irritation, and
genetic predisposition.

A nurse is reinforcing teaching to a client who has a new prescription for tantalizing
ointment to treat a skin infection. Which of the following statements by the client
indicates an understanding of the treatment?

● I will wash the area with soap and water before I apply the cream.

A nurse is providing skin care to a client who had urinary incontinence. Which of the
following actions should the nurse take?

● Apply a barrier cream to the skin.

A nurse is assisting with teaching a class about the function of the cells in the epidermis.
The nurse should include which of the following cells determine skin color?

● Melanocytes.

A nurse is assisting with teaching a class about expected changes to the skin in older
adults. Which of the following information should the nurse include?

● Increase in skin thinning, decrease in subcutaneous tissue, decrease in skin hydration.

A nurse is reinforcing teaching to a client who has cancer about foods that prevent
protein energy malnutrition. Which of the following foods should the nurse include in the
teaching?

● Cottage cheese, milk, tuna, fish, egg, and ham omelet.

A nurse is reinforcing teaching about TMN staging for cancer.

● M1.

A nurse is reinforcing teaching with a group of clients about common findings that can
indicate cancer. The nurse should instruct the client to monitor and report which of the
following findings?

● A nonhealing sore, change in bowel pattern, nagging cough.

A charge nurse in a long-term care facility will be implementing a new protocol to meet
the Joint Commission national safety goals of preventing healthcare-associated pressure
injuries. When informing the staff nurse about the new standards, the nurse should
emphasize which of the following actions is a priority?

● Identify the client at the greatest risk for developing pressure injury.

A nurse is contributing to the plan of care for a client who has a pressure injury on the
heel. Which of the following information should the nurse include in the plan?

● Provide the client with a diet high in vitamin C.

A nurse is planning preventative care for a client who is at risk for pressure ulcers and
requires bedrest. Which of the following actions should the nurse take?

● Reposition a client every two hours.

A nurse is reviewing the lab results for a client who has a pressure ulcer. Which of the
following identified an elevation in which of the following lab values to indicate the client
has an infection?

● WBC.

A nurse identifies a pressure ulcer after a client had a long, extensive recovery following
a surgical procedure. When completing an incident report about the pressure ulcer,
which of the following actions should the nurse take?
 ● Include any relevant statement that the client made about the pressure ulcer. (put in
quotation marks)

A nurse is caring for a client who has a stage three ulcer that now has some regulations
issued. Which of the following interventions should the nurse recommend for inclusion
in the lab results?

● Irrigate with sodium chloride.

A nurse is discussing pressure ulcer staging with a newly licensed nurse. Which of the
following statements should the nurse use to describe the stage three pressure ulcer?

● A deep crater without visible bone, tendon, or muscle.

A nurse is caring for a client who has Herpes Zoster. Which of the following actions
should the nurse take?

● Prepare to administer the Acyclovir.

The nurse is reinforcing teaching with a client who has Herpes Zoster. The nurse should
include which of the following statements in the teaching?

● Recurrence of infection can be triggered by stress or trauma.

A nurse is teaching an older adult client who has herpes zoster about the order of
occurrence of findings associated with this disorder. Identify the order in which the
findings typically occur.

1. Paresthesias
2. Redness & swelling
3. Appearance of vesicles
4. Weeping blisters
5. Crusted lesions
6. Postherpetic neuralgia.

The nurse is caring for a client who has recurrence Herpes Simplex 1 lesions. The nurse
should perform a focus assessment on which of the following areas of the spine?

● The mouth.

The nurse collected data from a client who has Herpes Zoster (Shingles). Which of the
following is expected?

● Painful vesicles followed by nerve pathway.

A nurse is reinforcing teaching with a client who has genital herpes caused by Herpes
Simplex Virus 2. Which statement by the client indicates understanding of the teaching?

● I can transmit the infection to another person even when I don't have symptoms.

The nurse is caring for a child who has tinea pedis?

 ● Athlete's foot?

A nurse is reviewing the plan of care for a client who has cellulitis of the legs. Which of
the following interventions should the nurse recommend?

● Wash daily with antibiotics.

A nurse in a provider's office is reinforcing teaching with a parent of a school-aged child

who has pediculosis capitis. Which of the following instructions should the nurse
include in the teaching?

● Wash the bedding and dry them for at least 20 minutes. (Permethrin is used once per
week.)

A school nurse is completing routine health evaluations for a school-aged child. Which
of the following manifestations should alert the nurse of a possible possibility of
pediculosis capitis?

● Reports of scalp-itchiness.

A nurse is caring for an adolescent client who comes to the provider's office for
treatment of acne vulgaris on her cheeks. Which of the following instructions should the
nurse reinforce with this client and her parents?

● Minimize sun exposure.

A nurse is reviewing discharge instructions with a client who has pruritus following
treatment for scabies. Which of the following instructions should the nurse include?

● Wear loose fitted clothing while you are experiencing itching.

A nurse is monitoring the fluid replacement for a client who has burns. Which of the
following clues should the nurse use in the first 24 hours of client burns?

● Lactated Ringers.

A nurse in a burn treatment center is caring for a client who is admitted with severe
burns to both lower extremities and is scheduled for an escharotomy. The client's
spouse asks the nurse what the procedure entails. Which of the following nursing
statements is appropriate?

● Large incisions will be made in the burn tissue to improve circulation.

A nurse is caring for a client who has partial-thickness and full-thickness burns of his
head, neck, and chest. The nurse should recognize which of the following is the priority
risk to the client?

● Airway obstruction.

A nurse is contributing to the plan of care for a school-aged child who has a moderate
partial thickness burn on both lower extremities. Which of the following interventions
should the nurse include?
 ● Administer pain medication 30 minutes before PT.

A nurse is caring for a client who was admitted with major burns to the head, neck, and
chest. Which of the following complications should the nurse identify as the greatest
error?

● Airway.

A nurse is caring for a client who has second and third degree burns and a prescription
for a high-calorie high-protein diet.

● Cheese and the potato.

A nurse is caring for a client following the application of a hypothermia bath. Which of
the following manifestations should the nurse identify as an indication that the client has
a superficial burn?

● Erythema.

A nurse is assisting with the care of a client who is brought to the emergency department
and has burn injuries. Which of the following findings should the nurse identify the client
has a deep partial thickness burn?

● Burn area is red in color with eschar present.

A nurse is collecting data on a client who has a major burn injury. The nurse should
recognize which of the following findings as a priority.

● Black sputum.

**A nurse is caring for a client who has an electrical burn. With the client's permission,
the nurse is answering questions from the family about his status. Which of the following
responses should the nurse make?

● He has an electrical burn. He is stable, and we will update you with any changes.

A nurse is assisting with a client who has partial thickness and full thickness burns of
the upper torso and the face. Which of the following actions should the nurse take to
prevent infection?

● Changing gloves between sites when providing wound care helps prevent the spread of
infection from one wound to another.

The nurse is reinforcing dietary teaching with a client who has a burn injury and adheres
to a strict vegetarian diet. Which of the following should the nurse recommend?

● Beans.

A nurse is assisting with the care of a client who sustains severe carbon monoxide
poisoning after being trapped in a burning building. Which of the following actions
should the nurse take?
 ● Administer 100% high-flow oxygen via a non-rebreathing mask.

The nurse is reviewing the urinalysis results of a client who reports urinary frequency
and burning. Which of the following findings should the nurse report to the provider?

● Microscopic hematuria.

NGN - Pressure Injuries

Stage 1 - Red intact skin, non-blanchable.
Stage 2 - Partial thickness, skin loss, exposed dermis.
Stage 3 - Full thickness - possible eschar.
Stage 4 - Can see muscle, bone, tendon.
Unstageable - Full thickness loss covered with slough/eschar.