Integumentary Management
Related to percutaneous absorption of the topical
Skin and Integumentary Diseases Part 1 30 items
1. When planning care for a male client with burns on the
upper torso, which nursing diagnosis should take the highest
priority?
Ineffective airway clearance related to edema of the
respiratory passages
Impaired physical mobility related to the disease process
Disturbed sleep pattern related to facility environment
Risk for infection related to breaks in the skin
2. In a female client with burns on the legs, which nursing
intervention helps prevent contractures?
Applying knee splints
Elevating the foot of the bed
Hyperextending the client’s palms
Performing shoulder range-of-motion exercises
3. A male client comes to the physician’s office for treatment
of severe sunburn. The nurse takes this opportunity to
discuss the importance of protecting the skin from the sun’s
damaging rays. Which instruction would best prevent skin
damage?
“Minimize sun exposure from 1 to 4 p.m. when the sun is
strongest.”
“Use a sunscreen with a sun protection factor of 6 or higher.”
“Apply sunscreen even on overcast days.”
“When at the beach, sit in the shade to prevent sunburn.”
4. A female client is brought to the emergency department
with second- and third-degree burns on the left arm, left
anterior leg, and anterior trunk. Using the Rule of Nines, what
is the total body surface area that has been burned?
18%
27%
30%
36%
5. Which nursing intervention can help a client maintain
healthy skin?
Keep the client well hydrated.
Avoid bathing the client with mild soap.
Remove adhesive tape quickly from the skin.
Recommend wearing tight-fitting clothes in hot weather.
6. A male client with psoriasis visits the dermatology clinic.
When inspecting the affected areas, the nurse expects to see
which type of secondary lesion?
Scale
Crust
Ulcer
Scar
7. A female adult client with atopic dermatitis is prescribed a
potent topical corticosteroid, to be covered with an occlusive
dressing. To address a potential client problem associated
with this treatment, the nurse formulates the nursing
diagnosis of Risk for injury. To complete the nursing diagnosis
statement, the nurse should add which “related-to” phrase?
Related to potential interactions between the topical
corticosteroid and other prescribed drugs
Related to vasodilatory effects of the topical corticosteroid
corticosteroid
Related to topical corticosteroid application to the face, neck,
and intertriginous sites
8. A male client is diagnosed with herpes simplex. Which
statement about herpes simplex infection is true?
During early pregnancy, herpes simplex infection may cause
spontaneous abortion or premature delivery.
Genital herpes simplex lesions are painless, fluid-filled
vesicles that ulcerate and heal in 3 to 7 days
Herpetic keratoconjunctivitis usually is bilateral and causes
systemic symptoms.
A client with genital herpes lesions can have sexual contact
but must use a condom.
9. A female client with a severe staphylococcal infection is
receiving the aminoglycoside gentamicin sulfate (Garamycin)
by the I.V. route. The nurse should assess the client for which
adverse reaction to this drug?
Aplastic anemia
Ototoxicity
Cardiac arrhythmias
Seizures
10. A male client is diagnosed with primary herpes genitalis.
Which instruction should the nurse provide?
“Apply one applicator of terconazole intravaginally at
bedtime for 7 days.”
“Apply one applicator of tioconazole intravaginally at
bedtime for 7 days.”
“Apply acyclovir ointment to the lesions every 3 hours, six
times a day for 7 days.”
“Apply sulconazole nitrate twice daily by massaging it gently
into the lesions.”
11. Nurse Bea plans to administer dexamethasone cream to a
client who has dermatitis over the anterior chest How should
the nurse apply this topical agent?
With a circular motion, to enhance absorption
With an upward motion, to increase blood supply to the
affected area
In long, even, outward, and downward strokes in the
direction of hair growth
In long, even, outward, and upward strokes in the direction
opposite hair growth
12. Nurse Meredith is caring for a wheelchair-bound client.
Which piece of equipment impedes circulation to the area it’s
meant to protect?
Polyurethane foam mattress
Ring or donut
Gel flotation pad
Water bed
13. Nurse Rudolf documents the presence of a scab on a
client’s deep wound. The nurse identifies this as which phase
of wound healing?
Inflammatory
Migratory
Proliferative
Maturation
14. In an industrial accident, a male client that weighs 155 lb
(70 kg) sustained full-thickness burns over 40% of his body.
He’s in the burn unit receiving fluid resuscitation. Which
observation shows that the fluid resuscitation is benefiting
the client?
A urine output consistently above 100 ml/hour
A weight gain of 4 lb (2 kg) in 24 hours
Body temperature readings all within normal limits
An electrocardiogram (ECG) showing no arrhythmias
15. A female client with herpes zoster is prescribed acyclovir
(Zovirax), 200 mg P.O. every 4 hours while awake. The nurse
should inform the client that this drug may cause:
palpitations.
dizziness.
diarrhea.
metallic taste.
16. A female client sees a dermatologist for a skin problem.
Later, the nurse reviews the client’s chart and notes that the
chief complaint was intertrigo. This term refers to which
condition?
Spontaneously occurring wheals
A fungus that enters the skin’s surface, causing infection
Inflammation of a hair follicle
Irritation of opposing skin surfaces caused by friction
17. A male client who has suffered a cerebrovascular accident
(CVA) is too weak to move on his own. To help the client
avoid pressure ulcers, the nurse should:
turn him frequently.
perform passive range-of-motion (ROM) exercises.
reduce the client’s fluid intake.
encourage the client to use a footboard.
18. A male client visits the physician’s office for treatment of
a skin disorder. As a primary treatment, the nurse expects
the physician to prescribe:
an I.V. corticosteroid.
an I.V. antibiotic.
an oral antibiotic.
a topical agent.
19. While in a skilled nursing facility, a male client contracted
scabies, which is diagnosed the day after discharge. The client
is living at her daughter’s home, where six other persons are
living. During her visit to the clinic, she asks a staff nurse,
“What should my family do?” The most accurate response
from the nurse is:
“All family members will need to be treated.”
“If someone develops symptoms, tell him to see a physician
right away.”
“Just be careful not to share linens and towels with family
members.”
“After you’re treated, family members won’t be at risk for
contracting scabies.”
20. When caring for a male client with severe impetigo, the
nurse should include which intervention in the plan of care?
Placing mitts on the client’s hands
Administering systemic antibiotics as prescribed
Applying topical antibiotics as prescribed
Continuing to administer antibiotics for 21 days as prescribed
21. A female client with second- and third-degree burns on
the arms receives autografts. Two days later, the nurse finds
the client doing arm exercises. The nurse knows that this
client should avoid exercise because it may:
dislodge the autografts.
increase edema in the arms.
increase the amount of scarring.
decrease circulation to the fingers.
22. Nurse Troy discovers scabies when assessing a client who
has just been transferred to the medical-surgical unit from
the day surgery unit. To prevent scabies infection in other
clients, the nurse should:
wash hands, apply a pediculicide to the client’s scalp, and
remove any observable mites.
isolate the client’s bed linens until the client is no longer
infectious.
notify the nurse in the day surgery unit of a potential scabies
outbreak.
place the client on enteric precautions.
23. Dr. Smith prescribes an emollient for a client with pruritus
of recent onset. The client asks why the emollient should be
applied immediately after a bath or shower. How should the
nurse respond?
“This makes the skin feel soft.”
“This prevents evaporation of water from the hydrated
epidermis.”
“This minimizes cracking of the dermis.”
“This prevents inflammation of the skin.”
24. Following a full-thickness (third-degree) burn of his left
arm, a female client is treated with artificial skin. The client
understands postoperative care of artificial skin when he
states that during the first 7 days after the procedure, he will
restrict:
range of motion.
protein intake.
going outdoors.
fluid ingestion.
25. A male client with a solar burn of the chest, back, face,
and arms is seen in urgent care. The nurse’s primary concern
should be:
fluid resuscitation.
infection.
body image.
pain management.
26. The nurse is providing home care instructions to a client
who has recently had a skin graft. It’s most important that
the client remember to:
use cosmetic camouflage techniques.
protect the graft from direct sunlight.
continue physical therapy.
apply lubricating lotion to the graft site.
27. A male client is diagnosed with gonorrhea. When
teaching the client about this disease, the nurse should
include which instruction?
“Avoid sexual intercourse until you’ve completed treatment,
which takes 14 to 21 days.”
“Wash your hands thoroughly to avoid transferring the
infection to your eyes.”
“If you have intercourse before treatment ends, tell sexual
partners of your status and have them wash well after
intercourse.”
“If you don’t get treatment, you may develop meningitis and
suffer widespread central nervous system (CNS) damage.”
28. A female client with atopic dermatitis is prescribed
medication for photochemotherapy. The nurse teaches the
client about the importance of protecting the skin from
ultraviolet light before drug administration and for 8 hours
afterward and stresses the need to protect the eyes. After
administering medication for photochemotherapy, the client
must protect the eyes for:
4 hours.
8 hours.
24 hours.
48 hours.
29. A female client with genital herpes simplex is being
treated in the outpatient department. The nurse teaches her
about measures that may prevent herpes recurrences and
emphasizes the need for prompt treatment if complications
arise. Genital herpes simplex increases the risk of:
cancer of the ovaries.
cancer of the uterus.
cancer of the cervix.
cancer of the vagina.
30. Which of the following is the initial intervention for a
male client with external bleeding?
Elevation of the extremity
Pressure point control
Direct pressure
Application of a tourniquet
Answers and Rationales
1. Answer A. When caring for a client with upper torso
burns, the nurse’s primary goal is to maintain
respiratory integrity. Therefore, option A should take
the highest priority. Option B isn’t appropriate because
burns aren’t a disease. Option C and D may be
appropriate, but don’t command a higher priority than
option A because they don’t reflect immediately life-
threatening problems.
2. Answer A. Applying knee splints prevents leg
contractures by holding the joints in a position of
function. Elevating the foot of the bed can’t prevent
contractures because this action doesn’t hold the
joints in a position of function. Hyperextending a body
part for an extended time is inappropriate because it
can cause contractures. Performing shoulder range-of-
motion exercises can prevent contractures in the
shoulders, but not in the legs.
3. Answer C. Sunscreen should be applied even on
overcast days, because the sun’s rays are as damaging
then as on sunny days. The sun is strongest from 10
a.m. to 2 p.m. (11 a.m. to 3 p.m. daylight saving time)
— not from 1 to 4 p.m. Sun exposure should be
minimized during these hours. The nurse should
recommend sunscreen with a sun protection factor of
at least 15. Sitting in the shade when at the beach
doesn’t guarantee protection against sunburn because
sand, concrete, and water can reflect more than half
the sun’s rays onto the skin.
4. Answer D. The Rule of Nines divides body surface area
into percentages that, when totaled, equal 100%.
According to the Rule of Nines, the arms account for
9% each, the anterior legs account for 9% each, and
the anterior trunk accounts for 18%. Therefore, this
client’s burns cover 36% of the body surface area.
5. Answer A. Keeping the client well hydrated helps
prevent skin cracking and infection because intact
healthy skin is the body’s first line of defense. To help
a client maintain healthy skin, the nurse should avoid
strong or harsh detergents and should use mild soap.
The nurse shouldn’t remove adhesive tape quickly
because this action can strip or scrape the skin. The
nurse should recommend wearing loose-fitting — not
tight-fitting — clothes in hot weather to promote heat
loss by evaporation.
6. Answer A. A scale is the characteristic secondary lesion
occurring in psoriasis. Although crusts, ulcers, and
scars also are secondary lesions in skin disorders, they
don’t accompany psoriasis.
7. Answer C. A potent topical corticosteroid may increase
the client’s risk for injury because it may be absorbed
percutaneously, causing the same adverse effects as
systemic corticosteroids. Topical corticosteroids aren’t
involved in significant drug interactions. These
preparations cause vasoconstriction, not vasodilation.
A potent topical corticosteroid rarely is prescribed for
use on the face, neck, or intertriginous sites because
application on these areas may lead to increased
adverse effects.
8. Answer A. Herpes simplex may be passed to the fetus
transplacentally and, during early pregnancy, may
cause spontaneous abortion or premature delivery.
Genital herpes simplex lesions typically are painful,
fluid-filled vesicles that ulcerate and heal within 1 to 2
weeks. Herpetic keratoconjunctivitis usually is
unilateral and causes localized symptoms, such as
conjunctivitis. A client with genital herpes lesions
should avoid all sexual contact to prevent spreading
the disease.
9. Answer B. The most significant adverse reactions to
gentamicin and other aminoglycosides are ototoxicity
(indicated by vertigo, tinnitus, and hearing loss) and
nephrotoxicity (indicated by urinary cells or casts,
oliguria, proteinuria, and reduced creatinine
clearance). These adverse reactions are most common
in elderly and dehydrated clients, those with renal
impairment, and those receiving concomitant therapy
with another potentially ototoxic or nephrotoxic drug.
Gentamicin isn’t associated with aplastic anemia,
cardiac arrhythmias, or seizures.
10. Answer C. A client with primary herpes genitalis should
apply topical acyclovir ointment in sufficient quantities
to cover the lesions every 3 hours, six times a day for 7
days. Terconazole and tioconazole are used to treat
vulvovaginal candidiasis. Sulconazole nitrate is used to
treat tinea versicolor.
11. Answer C. When applying a topical agent, the nurse
should begin at the midline and use long, even,
outward, and downward strokes in the direction of
hair growth. This application pattern reduces the risk
of follicle irritation and skin inflammation.
12. Answer B. Rings or donuts aren’t to be used because
they restrict circulation. Foam mattresses evenly
distribute pressure. Gel pads redistribute with the
client’s weight. The water bed also distributes pressure
over the entire surface.
13. Answer B. The scab formation is found in the migratory
phase. It is accompanied by migration of epithelial
cells, synthesis of scar tissue by fibroblasts, and
development of new cells that grow across the wound.
In the inflammatory phase, a blood clot forms,
epidermis thickens, and an inflammatory reaction
occurs in the subcutaneous tissue. During the
proliferative phase, the actions of the migratory phase
continue and intensify, and granulation tissue fills the
wound. In the maturation phase, cells and vessels
return to normal and the scab sloughs off.
14. Answer A. In a client with burns, the goal of fluid
resuscitation is to maintain a mean arterial blood
pressure that provides adequate perfusion of vital
structures. If the kidneys are adequately perfused,
they will produce an acceptable urine output of at
least 0.5 ml/kg/hour. Thus, the expected urine output
of a 155-lb client is 35 ml/hour, and a urine output
consistently above 100 ml/hour is more than
adequate. Weight gain from fluid resuscitation isn’t a
goal. In fact, a 4-lb weight gain in 24 hours suggests
third spacing. Body temperature readings and ECG
interpretations may demonstrate secondary benefits
of fluid resuscitation but aren’t primary indicators.
15. Answer C. Oral acyclovir may cause such adverse GI
effects as diarrhea, nausea, and vomiting. It isn’t
associated with palpitations, dizziness, or a metallic
taste.
16. Answer D. Intertrigo refers to irritation of opposing
skin surfaces caused by friction. Spontaneously
occurring wheals occur in hives. A fungus that enters
the skin surface and causes infection is a
dermatophyte. Inflammation of a hair follicle is called
folliculitis.
17. Answer A. The most important intervention to prevent
pressure ulcers is frequent position changes, which
relieve pressure on the skin and underlying tissues. If
pressure isn’t relieved, capillaries become occluded,
reducing circulation and oxygenation of the tissues and
resulting in cell death and ulcer formation. During
passive ROM exercises, the nurse moves each joint
through its range of movement, which improves joint
mobility and circulation to the affected area but
doesn’t prevent pressure ulcers. Adequate hydration is
necessary to maintain healthy skin and ensure tissue
repair. A footboard prevents plantar flexion and
footdrop by maintaining the foot in a dorsiflexed
position.
18. Answer D. Although many drugs are used to treat skin
disorders, topical agents — not I.V. or oral agents —
are the mainstay of treatment.
19. Answer A. When someone in a group of persons
sharing a home contracts scabies, each individual in
the home needs prompt treatment whether he’s
symptomatic or not. Towels and linens should be
washed in hot water. Scabies can be transmitted from
one person to another before symptoms develop.
20. Answer B. Impetigo is a contagious, superficial skin
infection caused by beta-hemolytic streptococci. If the
condition is severe, the physician typically prescribes
systemic antibiotics for 7 to 10 days to prevent
glomerulonephritis, a dangerous complication. The
client’s nails should be kept trimmed to avoid
scratching; however, mitts aren’t necessary. Topical
antibiotics are less effective than systemic antibiotics
in treating impetigo.
21. Answer A. Because exercising the autograft sites may
dislodge the grafted tissue, the nurse should advise the
client to keep the grafted extremity in a neutral
position. None of the other options results from
exercise
22. Answer B. To prevent the spread of scabies in other
hospitalized clients, the nurse should isolate the
client’s bed linens until the client is no longer
infectious — usually 24 hours after treatment begins.
Other required precautions include using good hand-
washing technique and wearing gloves when applying
the pediculicide and during all contact with the client.
Although the nurse should notify the nurse in the day
surgery unit of the client’s condition, a scabies
epidemic is unlikely because scabies is spread through
skin or sexual contact. This client doesn’t require
enteric precautions because the mites aren’t found on
feces.
23. Answer B. Applying an emollient immediately after
taking a bath or shower prevents evaporation of water
from the hydrated epidermis, the skin’s upper layer.
Although emollients make the skin feel soft, this effect
occurs whether or not the client has just bathed or
showered. An emollient minimizes cracking of the
epidermis, not the dermis (the layer beneath the
epidermis). An emollient doesn’t prevent skin
inflammation.
24. Answer A. To prevent disruption of the artificial skin’s
adherence to the wound bed, the client should restrict
range of motion of the involved limb. Protein intake
and fluid intake are important for healing and
regeneration and shouldn’t be restricted. Going
outdoors is acceptable as long as the left arm is
protected from direct sunlight.
25. Answer D. With a superficial partial thickness burn
such as a solar burn (sunburn), the nurse’s main
concern is pain management. Fluid resuscitation and
infection become concerns if the burn extends to the
dermal and subcutaneous skin layers. Body image
disturbance is a concern that has lower priority than
pain management.
26. Answer B. To avoid burning and sloughing, the client
must protect the graft from direct sunlight. The other
three interventions are helpful to the client and his
recovery but are less important.
27. Answer B. Adults and children with gonorrhea may
develop gonococcal conjunctivitis by touching the eyes
with contaminated hands. The client should avoid
sexual intercourse until treatment is completed, which
usually takes 4 to 7 days, and a follow-up culture
 confirms that the infection has been eradicated. A
client who doesn’t refrain from intercourse before
treatment is completed should use a condom in
addition to informing sex partners of the client’s
health status and instructing them to wash well after
intercourse. Meningitis and widespread CNS damage
are potential complications of untreated syphilis, not
gonorrhea.
28. Answer D. To prevent eye discomfort, the client must
protect the eyes for 48 hours after taking medication
for photochemotherapy. Protecting the eyes for a
shorter period increases the risk of eye injury.
29. Answer C. A female client with genital herpes simplex
is at increased risk for cervical cancer. Genital herpes
simplex isn’t a risk factor for cancer of the ovaries,
uterus, or vagina.
30. Answer C. Applying direct pressure to an injury is the
initial step in controlling bleeding. For severe or
arterial bleeding, pressure point control can be used.
Pressure points are those areas where large blood
vessels can be compressed against bone: femoral,
brachial, facial, carotid, and temporal artery sites.
Elevation reduces the force of flow, but direct pressure
is the first step. A tourniquet may further damage the
injured extremity and should be avoided unless all
other measures have failed.
Skin and Integumentary Diseases Part 2 30 items
1. Nurse Jay is performing wound care. Which of the
following practices violates surgical asepsis?
Holding sterile objects above the waist
Considering a 1″ edge around the sterile field as being
contaminated
Pouring solution onto a sterile field cloth
Opening the outermost flap of a sterile package away from
the body
2. During the acute phase of a burn, the nurse in-charge
should assess which of the following?
Client’s lifestyle
Alcohol use
Tobacco use
Circulatory status
3. Nurse Kate is changing a dressing and providing wound
care. Which activity should she perform first?
Assess the drainage in the dressing.
Slowly remove the soiled dressing
Wash hands thoroughly.
Put on latex gloves.
4. Nurse May is caring for an elderly bedridden adult. To
prevent pressure ulcers, which intervention should the nurse
include in the plan of care?
Turn and reposition the client at least once every 8 hours.
Vigorously massage lotion into bony prominences.
Post a turning schedule at the client’s bedside.
Slide the client, rather than lifting, when turning.
5. Nurse Jane formulates a nursing diagnosis of Impaired
physical mobility for a client with third-degree burns on the
lower portions of both legs. To complete the nursing
diagnosis statement, the nurse should add which “related-to”
phrase?
Related to fat emboli
Related to infection
Related to femoral artery occlusion
Related to circumferential eschar
6. The nurse is assessing for the presence of cyanosis in a
male dark-skinned client. The nurse understands that which
body area would provide the best assessment?
Lips
Sacrum
Earlobes
Back of the hands
7. Which of the following individuals is least likely to be at
risk of developing psoriasis?
A 32 year-old-African American
A woman experiencing menopause
A client with a family history of the disorder
An individual who has experienced a significant amount of
emotional distress
8. Which of the following clients would least likely be at risk
of developing skin breakdown?
A client incontinent of urine feces
A client with chronic nutritional deficiencies
A client with decreased sensory perception
A client who is unable to move about and is confined to bed
9. The nurse prepares to care for a male client with acute
cellulites of the lower leg. The nurse anticipates that which of
the following will be prescribed for the client?
Cold compress to the affected area
Warm compress to the affected area
Intermittent heat lamp treatments four times daily
Alternating hot and cold compresses continuously
10. The clinic nurse assesses the skin of a white characteristic
is associated with this skin disorder?
Clear, thin nail beds
Red-purplish scaly lesions
Oily skin and no episodes of pruritus
Silvery-white scaly patches on the scalp, elbow, knees, and
sacral regions
11. The clinic nurse notes that the physician has documented
a diagnosis of herpes zoster (shingles) in the male client’s
chart. Based on an understanding of the cause of this
disorder, the nurse determines that this definitive diagnosis
was made following which diagnostic test?
Patch test
Skin biopsy
Culture of the lesion
Woo’s light examination
12. The nurse is assigned to care for a female client with
herpes zoster (Shingles). Which of the following
characteristics would the nurse expect to note when
assessing the lesions of this infection?
Clustered skin vesicles
A generalized body rash
Small blue-white spots with a red base
A fiery red, edematous rash on the cheeks
13. When assessing a lesion diagnosed as malignant
melanoma, the nurse in-charge most likely expects to note
which of the following?
An irregular shaped lesion
A small papule with a dry, rough scale
A firm, nodular lesion topped with crust
A pearly papule with a central crater and a waxy border
14. The nurse prepares discharge instructions for a male
client following cryosurgery for the treatment of a malignant
skin lesion. Which of the following should the nurse include
in the instruction?
Avoid showering for 7 to 10 days
Apply ice to the site to prevent discomfort
Apply alcohol-soaked dressing twice a day
Clean the site with hydrogen peroxide to prevent infection
15. Nurse Carl reviews the client’s chart and notes that the
physician has documented a diagnosis of paronychia. Based
on this diagnosis, which of the following would the nurse
expect to note during the assessment?
Red shiny skin around the nail bed
White taut skin in the popliteal area
White silvery patches on the elbows
Swelling of the skin near the parotid gland
16. A male client arrives at the emergency room and has
experienced frostbites to the right hand. Which of the
following would the nurse note on assessment of the client’s
hand?
A pink, edematous hand
A fiery red skin with edema in the nail beds
Black fingertips surrounded by an erythematous rash
A white color to the skin, which is insensitive to touch
17. The evening nurse reviews the nursing documentation in
the male client’s chart and notes that the day nurse has
documented that the client has a stage II pressure ulcer in
the sacral area. Which of the following would the nurse
expect to note on assessment of the client’s sacral area?
Intact skin
Full-thickness skin loss
Exposed bone, tendon, or muscle
Partial-thickness skin loss of the dermis
18. Nurse Ivy is implementing a teaching plan to a group of
adolescents regarding the causes of acne. Which of the
following is an appropriate nursing statement regarding the
cause of this disorder?
“Acne is caused by oily skin”
“The actual cause is not known”
“Acne is caused by eating chocolate”
“Acne is caused as a result of exposure to heat and
humidity”
19. The nurse is reviewing the health care record of a male
clients scheduled to be seen at the health care clinic. The
nurse determines that which of the following individuals is at
the greatest risk for development of an integumentary
disorder?
An adolescent
An older female
A physical education teacher
An outdoor construction worker
20. A male client schedule for a skin biopsy is concerned and
asks the nurse how painful the procedure is. The appropriate
response by the nurse is:
“There is no pain associated with this procedure”
“The local anesthetic may cause a burning or stinging
sensation”
A preoperative medication will be given so you will be
sleeping and will not feel any pain”
“There is some pain, but the physician will prescribe an
opioid analgesic following the procedure”
21. The nurse is teaching a female client with a leg ulcer
about tissue repair and wound healing. Which of the
following statements by the client indicates effective
teaching?
“I’ll limit my intake of protein.”
“I’ll make sure that the bandage is wrapped tightly.”
“My foot should feel cold.”
“I’ll eat plenty of fruits and vegetables.”
22. Following a full-thickness (third-degree) burn of his left
arm, a male client is treated with artificial skin. The client
understands postoperative care of artificial skin when he
states that during the first 7 days after the procedure, he will
restrict:
range of motion.
protein intake.
going outdoors.
fluid ingestion.
23. Following a small-bowel resection, a male client develops
fever and anemia. The surface surrounding the surgical
wound is warm to the touch and necrotizing fasciitis is
suspected. Another manifestation that would most suggest
necrotizing fasciitis is:
erythema.
leukocytosis.
pressurelike pain.
swelling.
24. While in a skilled nursing facility, a female client
contracted scabies, which is diagnosed the day after
discharge. The client is living at her daughter’s home, where
six other persons are living. During her visit to the clinic, she
asks a staff nurse, “What should my family do?” The most
accurate response from the nurse is:
“All family members will need to be treated.”
“If someone develops symptoms, tell him to see a physician
right away.”
“Just be careful not to share linens and towels with family
members.”
“After you’re treated, family members won’t be at risk for
contracting scabies.”
25. The nurse is assessing a male client admitted with
second- and third-degree burns on the face, arms, and chest.
Which finding indicates a potential problem?
Partial pressure of arterial oxygen (PaO2) value of 80 mm Hg
Urine output of 20 ml/hour
White pulmonary secretions
Rectal temperature of 100.6° F (38° C)
26. A female client exhibits s purplish bruise to the skin after
a fall. The nurse would document this finding most accurately
using which of the following terms?
Purpura
Petechiae
Ecchymosis
Erythema
27. An older client’s physical examination reveals the
presence of a number of bright red-colored lesions scattered
on the trunk and tights. The nurse interprets that this
indicates which of the following lesions due to alterations in
blood vessels of the skin?
Cherry angioma
Spider angioma
Venous star
Purpura
28. A nurse is reviewing the medical record of a male client to
be admitted to the nursing unit and notes documentation of
reticular skin lesions. The nurse expects that these lesions will
appear to be:
Ring-shaped
Linear
Shaped like an arc
Net-like appearance
29. A male client seen in an ambulatory clinic has a butterfly
rash across the nose. The nurse interprets that this finding is
consistent with early manifestations of which of the following
disorders?
Hyperthyroidism
Perncious anemia
Cardiopulmonary disorders
Systemic lupus erythematosus (SLE)
30. A female client with cellulites of the lower leg has had
cultures done on the affected area. The nurse reading the
culture report understands that which of the following
organisms is not part of the normal flora of the skin?
Staphylococcus epidermidis
Staphylococcus aureus
Escherichia coli (E. coli)
Candida albicans
Answers and Rationales
1. Answer C. Pouring solution onto a sterile field cloth
violates surgical asepsis because moisture penetrating
the cloth can carry microorganisms to the sterile field
via capillary action. The other options are practices
that help ensure surgical asepsis.
2. Answer D. During the acute phase of a burn, the nurse
should assess the client’s circulatory and respiratory
status, vital signs, fluid intake and output, ability to
move, bowel sounds, wounds, and mental status.
Information about the client’s lifestyle and alcohol and
tobacco use may be obtained later when the client’s
condition has stabilized.
3. Answer C. When caring for a client, the nurse must first
wash her hands. Putting on gloves, removing the
dressing, and observing the drainage are all parts of
performing a dressing change after hand washing is
completed.
4. Answer C. A turning schedule with a signing sheet will
help ensure that the client gets turned and, thus, help
prevent pressure ulcers. Turning should occur every 1
to 2 hours — not every 8 hours — for clients who are in
bed for prolonged periods. The nurse should apply
lotion to keep the skin moist but should avoid vigorous
massage, which could damage capillaries. When
moving the client, the nurse should lift — rather than
slide — the client to avoid shearing.
5. Answer D. As edema develops on circumferential
burns, eschar forms a tight, constricting band,
compromising circulation to the extremity distal to the
circumferential site and impairing physical mobility.
This client isn’t likely to develop fat emboli unless long
bone or pelvic fractures are present. Infection doesn’t
alter physical mobility. A client with burns on the
lower portions of both legs isn’t likely to have femoral
artery occlusion.
6. Answer A. In a dark-skinned client, the nurse examines
the lips, tongue, nail beds, conjunctivae, and palms of
the hands and soles of the feet at regular intervals for
subtle color changes. In a client with cyanosis, the lips
and tongue are gray; the palms, soles, conjunctivae,
and nail beds have a bluish tinge.
7. Answer A. Psoriasis occurs equally among women and
men, although the incidence is lower in darker skinned
races and ethnic groups. A genetic predisposition has
been recognized in some cases. Emotional distress,
trauma, systemic illness, seasonal changes, and
hormonal changes are linked to exacerbations.
8. Answer C. Bed or chair confinement, inability to move,
loss of bowel or bladder control, poor nutrition, absent
or inconsistent caregiving, and decreased sensory
perception can contribute to the development of skin
breakdown. The least likely risk, as presented in the
options, is the decreased sensory perception. Options
A, B, and D identify physiological conditions, which are
the risk priorities.
9. Answer B. Cellulitis is a skin infection into deeper
dermal and subcutaneous tissues that results in a deep
red erythema without sharp borders and spreads
widely throughout tissue spaces. Warm compresses
may be used to decrease the discomfort, erythema,
and edema. After tissue and blood cultures are
obtained, antibiotics will be initiated. The nurse should
provide supportive care as prescribed to manage
symptoms such as fatigue, fever, chills, headache, and
myalgia. Heat lamps can cause more disruption to
already inflamed tissue. Cold compresses and
alternating cold and hot compresses are not the best
measures.
10. Answer D. Cellulitis is a skin infection into deeper
dermal and subcutaneous tissues that results in a deep
red erythema without sharp borders and spreads
widely throughout tissue spaces. Warm compresses
may be used to decrease the discomfort, erythema,
and edema. After tissue and blood cultures are
obtained, antibiotics will be initiated. The nurse should
 provide supportive care as prescribed to manage
symptoms such as fatigue, fever, chills, headache, and
myalgia. Heat lamps can cause more disruption to
already inflamed tissue. Cold compresses and
alternating cold and hot compresses are not the best
measures.
11. Answer C. With the classic presentation of herpes
zoster, the clinical examination is diagnostic. A viral
culture of the lesion provides the definitive diagnosis.
Herpes zoster (shingles) is caused by a reactivation of
the varicella-zoster virus, the virus that causes
chickenpox. A patch test is a skin test that involves the
administration of an allergen to the surface of the skin
to identify specific allergies. A biopsy would provide a
cytological examination of tissue. In a Wood’s light
examination, the skin is viewed under ultraviolet light
to identify superficial infections of the skin.
12. Answer A. The primary lesion of herpes zoster is a
vesicle. The classic presentation is grouped vesicles on
an erythematous base along a dermatome. Because
the lesions follow nerve pathways, they do not cross
the midline of the body. Options B, C, and D are
incorrect descriptions of herpes zoster.
13. Answer A. A melanoma is an irregularly shaped
pigmented papule or plaque with a red-, white-, or
blue-toned color. Basal cell carcinoma appears as a
pearly papule with a central crater and rolled waxy
border. Squamous cell carcinoma is a firm, nodular
lesion topped with a crust or a central area of
ulceration. Actinic keratosis, a premalignant lesion,
appears as a small macule or papule with a dry, rough,
adherent yellow or brown scale.
14. Answer D. Cryosurgery involves the local application of
liquid nitrogen to isolated lesions and causes cell death
and tissue destruction. The nurse informs the client
that swelling and increased tenderness of the treated
area can occur when the skin thaws. Tissue freezing is
followed by hemorrhagic blister formation in 1 to 2
days. The nurse instructs the client to clean the
treatment site with hydrogen peroxide to prevent
secondary infection. A topical antibiotic also may be
prescribed. Application of a warm, damp washcloth
intermittently to the site will provide relief from any
discomfort. Alcohol-soaked dressings will cause
irritation. The client does not need to avoid showering.
15. Answer A. Paronychia, or infection around the nail, is
characterized by red, shiny skin, often associated with
painful swelling. These infections frequently result
from trauma, picking at the nail, or disorders such as
dermatitis. Often, these become secondarily infected
with bacteria or fungus, which later involves the nail.
Warm soaks three or four times a day may reduce pain
and pressure; however, incision and drainage of the
inflamed site frequently are required. Options B, C,
and D are incorrect.
16. Answer D. Assessment findings in frostbite include a
white or blue color; the skin will be hard, cold, and
insensitive to touch. As thawing occurs, flushing of the
skin, the development of blisters or blebs, or tissue
edema appears. Options A, B, and C are incorrect.
17. Answer D. In a stage II pressure ulcer, the skin is not
intact. Partial-thickness skin loss of the dermis has
occurred. It presents as a shallow open ulcer with a
red-pink wound bed, without slough. It may also
present as an intact, open or ruptured, serum-filled
blister. The skin is intact in stage I. Full-thickness skin
loss occurs in stage 3. Exposed bone, tendon, or muscle
is present in stage 4.
18. Answer B. The actual cause of acne is unknown. Oily
skin or the consumption of foods such as chocolate,
nuts, or fatty foods are not causes of acne.
Exacerbations that coincide with the menstrual cycle
result from hormonal activity. Heat, humidity, and
excessive perspiration may play a role in exacerbating
acne but does not cause it.
19. Answer D. Prolonged exposure to the sun, unusual
cold, or other conditions can damage the skin. The
outdoor construction worker would fit into a high-risk
category for the development of an integumentary
disorder. An adolescent may be prone to the
development of acne, but this does not occur in all
adolescents. Immobility and lack of nutrition would
increase the older person’s risk but the older client is
not at as high a risk as the outdoor construction
worker. The physical education teacher is at low or no
risk of developing an integumentary problem.
20. Answer B. Depending on the size and location of the
lesion, a biopsy is usually a quick and almost painless
procedure. The most common source of pain is the
initial local anesthetic, which can produce a burning or
stinging sensation. Preoperative medication is not
necessary with this procedure.
21. Answer D. For effective tissue healing, adequate intake
of protein, vitamin A, B complex, C, D, E, and K are
needed. Therefore, the client should eat a high protein
diet with plenty of fruits and vegetables to provide
these nutrients. The bandage should be secure but not
too tight to impede circulation to the area (needed for
tissue repair). If the client’s foot feels cold, circulation
is impaired, thus inhibiting wound healing.
22. Answer A. To prevent disruption of the artificial skin’s
adherence to the wound bed, the client should restrict
range of motion of the involved limb. Protein intake
and fluid intake are important for healing and
regeneration and shouldn’t be restricted. Going
outdoors is acceptable as long as the left arm is
protected from direct sunlight.
23. Answer C. Severe pressure like pain out of proportion
to visible signs distinguishes necrotizing fasciitis from
cellulitis. Erythema, leukocytosis, and swelling are
present in both cellulitis and necrotizing fasciitis.
24. Answer A. When someone in a group of persons
sharing a home contracts scabies, each individual in
the home needs prompt treatment whether he’s
symptomatic or not. Towels and linens should be
washed in hot water. Scabies can be transmitted from
one person to another before symptoms develop.
25. Answer B. A urine output of less than 40 ml/hour in a
client with burns indicates a fluid volume deficit. This
client’s PaO2 value falls within the normal range (80 to
100 mm Hg). White pulmonary secretions also are
normal. The client’s rectal temperature isn’t
significantly elevated and probably results from the
fluid volume deficit.
26. Answer C. Ecchymosis is a type of purpuric lesion and
also is known as a bruise. Purpura is an umbrella term
 that incorporates ecchymoses and petechiae.
Petechiae are pinpoint hemorrhages and are another
form of purpura. Erythema is an area of redness on the
skin.
27. Answer A. Cherry angioma occurs with increasing age
and has no clinical significance. It appears as a small,
round, bright red–colored lesion on the trunk or
extremities. Spider angiomas have a bright red center
with legs that radiate outward. These lesions
commonly are seen in liver disease and vitamin B
deficiency, although they occasionally can occur
without underlying pathology. A venous star results
from increased pressure in veins, usually in the lower
legs, and has an irregularly shaped bluish center with
radiating branches. Purpura results from hemorrhage
into the skin.
28. Answer D. Reticular skin lesions resemble a net in
appearance. Annular lesions are ring-shaped, whereas
linear lesions appear in a straight line. Arciform lesions
are shaped like an arc.
29. Answer D. An early sign of SLE is the appearance of a
butterfly rash across the nose. Hyperthyroidism often
leads to moist skin and increased perspiration.
Pernicious anemia would be manifested by pallor of
the skin. Cardiopulmonary disorders may lead to
clubbing of the fingers.
30. Answer C. E. coli normally is found in the intestines
and constitutes a common source of infection of
wounds and the urinary system. The other microbes
listed are part of the normal flora of the skin.
Burns 100 items
1) The burned client on admission is drooling and having
difficulty swallowing. What is the nurse’s best first action?
Assess level of consciousness and pupillary reactions.
Ask the client at what time food or liquid was last consumed.
Auscultate breath sounds over the trachea and mainstem
bronchi.
Measure abdominal girth and auscultate bowel sounds in all
four quadrants.
2) When should ambulation be initiated in the client who has
sustained a major burn?
When all full-thickness areas have been closed with skin
grafts
When the client’s temperature has remained normal for 24
hours
As soon as possible after wound debridement is complete
As soon as possible after resolution of the fluid shift
3) Which information obtained by assessment ensures that
the client’s respiratory efforts are currently adequate?
The client is able to talk.
The client is alert and oriented.
The client’s oxygen saturation is 97%.
The client’s chest movements are uninhibited
4) A client with a solar burn of the chest, back, face, and arms
is seen in urgent care. The nurse’s primary concern should
be:
fluid resuscitation
infection
body image
pain management
5) Which vitamin deficiency is most likely to be a long-term
consequence of a full-thickness burn injury?
Vitamin A
Vitamin B
Vitamin C
Vitamin D
6) In a female client with burns on the legs, which nursing
intervention helps prevent contractures?
Applying knee splints
Elevating the foot of the bed
Hyperextending the client’s palms
Performing shoulder range-of-motion exercises
7) The client, who is 2 weeks postburn with a 40% deep
partial-thickness injury, still has open wounds. On taking the
morning vital signs, the client is found to have a below-
normal temperature, is hypotensive, and has diarrhea. What
is the nurse’s best action?
Nothing, because the findings are normal for clients during
the acute phase of recovery.
Increase the temperature in the room and increase the IV
infusion rate.
Assess the client’s airway and oxygen saturation.
Notify the burn emergency team.
8) Which statement made by the client with facial burns who
has been prescribed to wear a facial mask pressure garment
indicates correct understanding of the purpose of this
treatment?
“After this treatment, my ears will not stick out.”
“The mask will help protect my skin from sun damage.”
“Using this mask will prevent scars from being permanent.”
“My facial scars should be less severe with the use of this
mask.”
9) A female client with second- and third-degree burns on the
arms receives autografts. Two days later, the nurse finds the
client doing arm exercises. The nurse knows that this client
should avoid exercise because it may:
dislodge the autografts.
increase edema in the arms.
increase the amount of scarring.
decrease circulation to the fingers.
10) A client is admitted to the hospital following a burn injury
to the left hand and arm. The client’s burn is described as
white and leathery with no blisters. Which degree of severity
is this burn?
first-degree burn
second-degree burn
third-degree burn
fourth-degree burn
11) Which of the following statements reflect the nursing
management of the patient with a white phosphorus
chemical burn?
Do not apply water to the burn.
Immediately drench the skin with running water from a
shower, hose or faucet.
Alternate applications of water and ice to the burn.
Wash off the chemical using warm water, then flush the skin
with cool water.
12) Which clinical manifestation indicates that the burned
client is moving into the fluid remobilization phase of
recovery?
Increased urine output, decreased urine specific gravity
Increased peripheral edema, decreased blood pressure
Decreased peripheral pulses, slow capillary refill
Decreased serum sodium level, increased hematocrit
13) The nurse is assessing a male client admitted with
second- and third-degree burns on the face, arms, and chest.
Which finding indicates a potential problem?
Partial pressure of arterial oxygen (PaO2) value of 80 mm Hg
Urine output of 20 ml/hour
White pulmonary secretions
Rectal temperature of 100.6° F (38° C)
14) What clinical manifestation should alert the nurse to
possible carbon monoxide poisoning in a client who
experienced a burn injury during a house fire?
Pulse oximetry reading of 80%
Expiratory stridor and nasal flaring
Cherry red color to the mucous membranes
Presence of carbonaceous particles in the sputum
15) During the acute phase, the nurse applied gentamicin
sulfate (topical antibiotic) to the burn before dressing the
wound. The client has all the following manifestations. Which
manifestation indicates that the client is having an adverse
reaction to this topical agent?
Increased wound pain 30 to 40 minutes after drug application
Presence of small, pale pink bumps in the wound beds
Decreased white blood cell count
Increased serum creatinine level
16) A 30-year-old homemaker fell asleep while smoking a
cigarette. She sustained severe burns of the face,neck,
anterior chest, and both arms and hands. Using the rule of
nines, which is the best estimate of total body-surface area
burned?
18%
22%
31%
40%
17) In an industrial accident, client who weighs 155 lb (70.3
kg) sustained full-thickness burns over 40% of his body. He’s
in the burn unit receiving fluid resuscitation. Which
observation shows that the fluid resuscitation is benefiting
the client?
A urine output consistently above 100 ml/hour.
A weight gain of 4 lb (1.8 kg) in 24 hours.
Body temperature readings all within normal limits
An electrocardiogram (ECG) showing no arrhythmias.
18) A client received burns to his entire back and left arm.
Using the Rule of Nines, the nurse can calculate that he has
sustained burns on what percentage of his body?
9%
18%
27%
36%
19) What is the priority nursing diagnosis for a client in the
rehabilitative phase of recovery from a burn injury?
Acute Pain
Impaired Adjustment
Deficient Diversional Activity
Imbalanced Nutrition: Less than Body Requirements
20) Following a full-thickness (third-degree) burn of his left
arm, a male client is treated with artificial skin. The client
understands postoperative care of artificial skin when he
states that during the first 7 days after the procedure, he will
restrict:
range of motion.
protein intake.
going outdoors.
fluid ingestion.
21) Which information obtained by assessment ensures that
the client’s respiratory efforts are currently adequate?
The client is able to talk.
The client is alert and oriented.
The client’s oxygen saturation is 97%.
The client’s chest movements are uninhibited
22) The burned client’s family ask at what point the client will
no longer be at increased risk for infection. What is the
nurse’s best response?
“When fluid remobilization has started.”
“When the burn wounds are closed.”
“When IV fluids are discontinued.”
“When body weight is normal.”
23) Twelve hours after the client was initially burned, bowel
sounds are absent in all four abdominal quadrants. What is
the nurse’s best action?
Reposition the client onto the right side.
Document the finding as the only action.
Notify the emergency team.
Increase the IV flow rate.
24) The newly admitted client has burns on both legs. The
burned areas appear white and leather-like. No blisters or
bleeding are present, and the client states that he or she has
little pain. How should this injury be categorized?
Full thickness
Partial-thickness deep
Partial-thickness superficial
Superficial
25) The nurse is caring for client with a new donor site that
was harvested to treat a new burn. The nurse position the
client to:
allow ventilation of the site
make the site dependent
avoid pressure on the site
keep the site fully covered
26)All of the following laboratory test results on a burned
client’s blood are present during the emergent phase. Which
result should the nurse report to the physician immediately?
Serum sodium elevated to 131 mmol/L (mEq/L)
Serum potassium 7.5 mmol/L (mEq/L)
Arterial pH is 7.32
Hematocrit is 52%
27) Which client factors should alert the nurse to potential
increased complications with a burn injury?
The client is a 26-year-old male.
The client has had a burn injury in the past.
The burned areas include the hands and perineum.
The burn took place in an open field and ignited the client’s
clothing.
28) The client has severe burns around the right hip. Which
position is most important to be emphasized by the nurse
that the client maintain to retain maximum function of this
joint?
Hip maintained in 30-degree flexion, no knee flexion
Hip flexed 90 degrees and knee flexed 90 degrees
Hip, knee, and ankle all at maximum flexion
Hip at zero flexion with leg flat
29) Which intervention is most important for the nurse to use
to prevent infection by cross-contamination in the client who
has open burn wounds?
Handwashing on entering the client’s room
Encouraging the client to cough and deep breathe
Administering the prescribed tetanus toxoid vaccine
Changing gloves between cleansing different burn areas
30) Ten hours after the client with 50% burns is admitted, her
blood glucose level is 90 mg/dL. What is the nurse’s best
action?
Notify the emergency team.
Document the finding as the only action.
Ask the client if anyone in her family has diabetes mellitus.
Slow the intravenous infusion of dextrose 5% in Ringer’s
lactate.
31) Nurse Jane formulates a nursing diagnosis of Impaired
physical mobility for a client with third-degree burns on the
lower portions of both legs. To complete the nursing
diagnosis statement, the nurse should add which “related-to”
phrase?
Related to fat emboli
Related to infection
Related to femoral artery occlusion
Related to circumferential eschar
32) A male client comes to the physician’s office for
treatment of severe sunburn. The nurse takes this
opportunity to discuss the importance of protecting the skin
from the sun’s damaging rays. Which instruction would best
prevent skin damage?
“Minimize sun exposure from 1 to 4 p.m. when the sun is
strongest.”
“Use a sunscreen with a sun protection factor of 6 or higher.”
“Apply sunscreen even on overcast days.”
“When at the beach, sit in the shade to prevent sunburn.”
33) When assessing a client with partial thickness burns over
60% of the body, which of the following should the nurse
report immediately?
Complaints of intense thirst
Moderate to severe pain
Urine output of 70 ml the 1st hour
Hoarseness of the voice
34) What clinical manifestation indicates that an
escharotomy is needed on a circumferential extremity burn?
The burn is full thickness rather than partial thickness.
The client is unable to fully pronate and supinate the
extremity.
Capillary refill is slow in the digits and the distal pulse is
absent.
The client cannot distinguish the sensation of sharp versus
dull in the extremity.
35) On admission to the emergency department the burned
client’s blood pressure is 90/60, with an apical pulse rate of
122. These findings are an expected result of what thermal
injury–related response?
Fluid shift
Intense pain
Hemorrhage
Carbon monoxide poisoning
36) The client with a dressing covering the neck is
experiencing some respiratory difficulty. What is the nurse’s
best first action?
Administer oxygen.
Loosen the dressing.
Notify the emergency team.
Document the observation as the only action.
37) The client has a deep partial-thickness injury to the
posterior neck. Which intervention is most important to use
during the acute phase to prevent contractures associated
with this injury?
Place a towel roll under the client’s neck or shoulder.
Keep the client in a supine position without the use of
pillows.
Have the client turn the head from side to side 90 degrees
every hour while awake.
Keep the client in a semi-Fowler’s position and actively raise
the arms above the head every hour while awake.
38) The burned client is ordered to receive intravenous
cimetidine, an H2 histamine blocking agent, during the
emergent phase. When the client’s family asks why this drug
is being given, what is the nurse’s best response?
“To increase the urine output and prevent kidney damage.”
“To stimulate intestinal movement and prevent abdominal
bloating.”
“To decrease hydrochloric acid production in the stomach
and prevent ulcers.”
“To inhibit loss of fluid from the circulatory system and
prevent hypovolemic shock.”
39) During the acute phase of a burn, the nurse in-charge
should assess which of the following?
Client’s lifestyle
Alcohol use
Tobacco use
Circulatory status
40) At what point after a burn injury should the nurse be
most alert for the complication of hypokalemia?
Immediately following the injury
During the fluid shift
During fluid remobilization
During the late acute phase
41) The burned client relates the following history of previous
health problems. Which one should alert the nurse to the
need for alteration of the fluid resuscitation plan?
Seasonal asthma
Hepatitis B 10 years ago
Myocardial infarction 1 year ago
Kidney stones within the last 6 month
42) What statement by the client indicates the need for
further discussion regarding the outcome of skin grafting
(allografting) procedures?
“For the first few days after surgery, the donor sites will be
painful.”
“Because the graft is my own skin, there is no chance it won’t
‘take’.”
“I will have some scarring in the area when the skin is
removed for grafting.”
“Once all grafting is completed, my risk for infection is the
same as it was before I was burned.”
43) The burned client newly arrived from an accident scene is
prescribed to receive 4 mg of morphine sulfate by IV push.
What is the most important reason to administer the opioid
analgesic to this client by the intravenous route?
The medication will be effective more quickly than if given
intramuscularly.
It is less likely to interfere with the client’s breathing and
oxygenation.
The danger of an overdose during fluid remobilization is
reduced.
The client delayed gastric emptying.
44) In assessing the client’s potential for an inhalation injury
as a result of a flame burn, what is the most important
question to ask the client on admission?
“Are you a smoker?”
“When was your last chest x-ray?”
“Have you ever had asthma or any other lung problem?”
“In what exact place or space were you when you were
burned?”
45) What additional laboratory test should be performed on
any African American client who sustains a serious burn
injury?
Total protein
Tissue type antigens
Prostate specific antigen
Hemoglobin S electrophoresis
46) In an industrial accident, a male client that weighs 155 lb
(70 kg) sustained full-thickness burns over 40% of his body.
He’s in the burn unit receiving fluid resuscitation. Which
observation shows that the fluid resuscitation is benefiting
the client?
A urine output consistently above 100 ml/hour
A weight gain of 4 lb (2 kg) in 24 hours
Body temperature readings all within normal limits
An electrocardiogram (ECG) showing no arrhythmias
47) Nursing care planning is based on the knowledge that the
first 24-48 hours post-burn are characterized by:
An increase in the total volume of intracranial plasma
Excessive renal perfusion with diuresis
Fluid shift from interstitial space
Fluid shift from intravascular space to the interstitial space
48) In reviewing the burned client’s laboratory report of
white blood cell count with differential, all the following
results are listed. Which laboratory finding indicates the
possibility of sepsis?
The total white blood cell count is 9000/mm3.
The lymphocytes outnumber the basophils.
The “bands” outnumber the “segs.”
The monocyte count is 1,800/mm3.
49) The newly admitted client has a large burned area on the
right arm. The burned area appears red, has blisters, and is
very painful. How should this injury be categorized?
Full thickness
Partial-thickness deep
Partial-thickness superficial
Superficial
50) The client has experienced an electrical injury, with the
entrance site on the left hand and the exit site on the left
foot. What are the priority assessment data to obtain from
this client on admission?
Airway patency
Heart rate and rhythm
Orientation to time, place, and person
Current range of motion in all extremities
51) The client who experienced an inhalation injury 6 hours
ago has been wheezing. When the client is assessed, wheezes
are no longer heard. What is the nurse’s best action?
Raise the head of the bed.
Notify the emergency team.
Loosen the dressings on the chest.
Document the findings as the only action.
52) Which statement by the client indicates correct
understanding of rehabilitation after burn injury?
“I will never be fully recovered from the burn.”
“I am considered fully recovered when all the wounds are
closed.”
“I will be fully recovered when I am able to perform all the
activities I did before my injury.”
“I will be fully recovered when I achieve the highest possible
level of functioning that I can.”
53) A female client is brought to the emergency department
with second- and third-degree burns on the left arm, left
anterior leg, and anterior trunk. Using the Rule of Nines, what
is the total body surface area that has been burned?
18%
27%
30%
36%
54) If a client has severe bums on the upper torso, which
item would be a primary concern?
Debriding and covering the wounds
Administering antibiotics
Frequently observing for hoarseness, stridor, and dyspnea
Establishing a patent IV line for fluid replacement
55) Contractures are among the most serious long-term
complications of severe burns. If a burn is located on the
upper torso, which nursing measure would be least effective
to help prevent contractures?
Changing the location of the bed or the TV set, or both, daily
Encouraging the client to chew gum and blow up balloons
Avoiding the use of a pillow for sleep, or placing the head in a
position of hyperextension
Helping the client to rest in the position of maximal comfort
56) Which intervention is most important to use to prevent
infection by autocontamination in the burned client during
the acute phase of recovery?
Changing gloves between wound care on different parts of
the client’s body.
Avoiding sharing equipment such as blood pressure cuffs
between clients.
Using the closed method of burn wound management.
Using proper and consistent handwashing.
57) Which type of fluid should the nurse expect to prepare
and administer as fluid resuscitation during the emergent
phase of burn recovery?
Colloids
Crystalloids
Fresh-frozen plasma
Packed red blood cells
58) An adult is receiving Total Parenteral Nutrition (TPN).
Which of the following assessment is essential?
evaluation of the peripheral IV site
confirmation that the tube is in the stomach
assess the bowel sound
fluid and electrolyte monitoring
59) When planning care for a male client with burns on the
upper torso, which nursing diagnosis should take the highest
priority?
Ineffective airway clearance related to edema of the
respiratory passages
Impaired physical mobility related to the disease process
Disturbed sleep pattern related to facility environment
Risk for infection related to breaks in the skin
60) What is the priority nursing diagnosis during the first 24
hours for a client with full-thickness chemical burns on the
anterior neck, chest, and all surfaces of the left arm?
Risk for Ineffective Breathing Pattern
Decreased Tissue Perfusion
Risk for Disuse Syndrome
Disturbed Body Image
61. 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 prior to discharge?
How to maintain home smoke detectors
Joining a community reintegration program
Learning to perform dressing changes
Options available for scar removal
62. A client who is admitted after a thermal burn injury has
the following vital signs: blood pressure, 70/40; heart rate,
140 beats/min; respiratory rate, 25/min. He is pale in color
and it is difficult to find pedal pulses. Which action will the
nurse take first?
Begin intravenous fluids.
Check the pulses with a Doppler device.
Obtain a complete blood count (CBC).
Obtain an electrocardiogram (ECG).
63. A client who was burned has crackles and a respiratory
rate of 40/min, and is coughing up blood-tinged sputum.
What action will the nurse take first?
Administer digoxin
Perform chest physiotherapy
Monitor urine output
Place the client in an upright position
64. How will the nurse position a client with a burn wound to
the posterior neck to prevent contractures?
Have the client turn the head from side to side.
Keep the client in a supine position without the use of
pillows.
Keep the client in a semi-Fowler’s position with her or his
arms elevated.
Place a towel roll under the client’s neck or shoulder.
65. On assessment, the nurse notes that the client has burns
inside the mouth and is wheezing. Several hours later, the
wheezing is no longer heard. What is the nurse’s next action?
Documenting the findings
Loosening any dressings on the chest
Raising the head of the bed
Preparing for intubation
66. Ten hours after the client with 50% burns is admitted, her
blood glucose level is 140 mg/dL. What is the nurse’s best
action?
Documents the finding
Obtains a family history for diabetes
Repeats the glucose measurement
Stops IV fluids containing dextrose
67. The client has a large burned area on the right arm. The
burned area appears pink, has blisters, and is very painful.
How will the nurse categorize this injury?
A. Full-thickness
Partial-thickness superficial
Partial-thickness deep
Superficial
68. The client has burns on both legs. These areas appear
white and leather-like. No blisters or bleeding are present,
and there is just a “small amount of pain.” How will the nurse
categorize this injury?
Full-thickness
Partial-thickness superficial
Partial-thickness deep
Superficial
69. The client has experienced an electrical injury of the
lower extremities. Which are the priority assessment data to
obtain from this client?
Current range of motion in all extremities
Heart rate and rhythm
Respiratory rate and pulse oximetry reading
Orientation to time, place, and person
70. The client has severe burns around the right hip. Which
position is most important to use to maintain maximum
function of this joint?
Hip maintained in 30-degree flexion
Hip at zero flexion with leg flat
Knee flexed at 30-degree angle
Leg abducted with foam wedge
71. The client who is burned is drooling and having difficulty
swallowing. Which action will the nurse take first?
Assesses level of consciousness and pupillary reactions
Ascertains the time food or liquid was last consumed
Auscultates breath sounds over the trachea and mainstem
bronchi
Measures abdominal girth and auscultates bowel sounds
72. The client with a full-thickness burn is being discharged to
home after a month in the hospital. His wounds are minimally
opened and he will be receiving home care. Which nursing
diagnosis has the highest priority?
Acute Pain
Deficient Diversional Activity
Impaired Adjustment
Imbalanced Nutrition: Less than Body Requirements
73. The client with a new burn injury asks the nurse why he is
receiving intravenous cimetidine (Tagamet). What is the
nurse’s best response?
“Tagamet will stimulate intestinal movement.”
“Tagamet can help prevent hypovolemic shock.”
“This will help prevent stomach ulcers.”
“This drug will help prevent kidney damage.”
74. The client with facial burns asks the nurse if he will ever
look the same. Which response is best for the nurse to
provide?
“With reconstructive surgery, you can look the same.”
“We can remove the scars with the use of a pressure
dressing.”
“You will not look exactly the same.”
“You shouldn’t start worrying about your appearance right
now.”
75. The 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 is the nurse’s best action?
Continuing to monitor the client
Increasing the temperature in the room
Increasing the rate of the intravenous fluids
Preparing to do a workup for sepsis
76. The family of a client who has been burned asks at what
point the client will no longer be at greater risk for infection.
What is the nurse’s best response?
“As soon as he finishes his antibiotic prescription.”
“As soon as his albumin level returns to normal.”
“When fluid remobilization has started.”
“When the burn wounds are closed.”
77. The nurse is conducting a home safety class. It is most
important for the nurse to include which information in the
teaching plan?
Have chimneys swept every 2 years.
Keep a smoke detector in each bedroom.
Use space heaters instead of gas heaters.
Use carbon monoxide detectors only in the garage.
78. The nurse provides wound care for a client 48 hours after
a burn injury. To achieve the desired outcome of the
procedure, which nursing action will be carried out first?
Applies silver sulfadiazine (Silvadene) ointment
Covers the area with an elastic wrap
Places a synthetic dressing over the area
Removes loose nonviable tissue
79. The nurse should teach the community that a minor burn
injury could be caused by what common occurrence?
Chimney sweeping every year
Cooking with a microwave oven
Use of sunscreen agents
Use of space heaters
80. The nurse uses topical gentamicin sulfate (Garamycin) on
a client’s burn injury. Which laboratory value will the nurse
monitor?
Creatinine
Red blood cells
Sodium
Magnesium level
81. 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?
Administer the prescribed tetanus toxoid vaccine.
Assess wounds for signs of infection.
Encourage the client to cough and breathe deeply.
Wash hands on entering the client’s room.
82. Three days after a burn injury, the client develops a
temperature of 100° F, white blood cell count of
15,000/mm3, and a white, foul-smelling discharge from the
wound. The nurse recognizes that the client is most likely
exhibiting symptoms of which condition?
Acute phase of the injury
Autodigestion of collagen
Granulation of burned tissue
Wound infection
83. Twelve hours after the client was initially burned, bowel
sounds are absent in all four abdominal quadrants. Which is
the nurse’s best action?
Administers a laxative
Documents the finding
Increases the IV flow rate
Repositions the client onto the right side
84. What intervention will the nurse implement to reduce a
client’s pain after a burn injury?
Administering morphine 4 mg intravenously.
Administering hydromorphone (Dilaudid) 4 mg
intramuscularly.
Applying ice to the burned area
Avoiding tactile stimulation
85. What statement indicates the client needs further
education regarding the skin grafting (allografting)?
“Because the graft is my own skin, there is no chance it won’t
‘take.’”
“For the first few days after surgery, the donor sites will be
painful.”
“I will have some scarring in the area when the skin is
removed for grafting.”
“I am still at risk for infection after the procedure.”
86. When providing care for a client with an acute burn
injury, which nursing intervention is most important to
prevent infection by autocontamination?
Avoiding sharing equipment such as blood pressure cuffs
between clients
Changing gloves between wound care on different parts of
the client’s body
Using the closed method of burn wound management
Using proper and consistent handwashing
87. Which assessment finding assists the nurse in confirming
inhalation injury?
Brassy cough
Decreased blood pressure
Nausea
Headache
88. Which finding indicates that fluid resuscitation has been
successful for a client with a burn injury?
Hematocrit = 60%
Heart rate = 130 beats/min
Increased peripheral edema
Urine output = 50 mL/hr
89. Which finding indicates to the nurse that a client with a
burn injury has a positive perception of his appearance?
Allowing family members to change his dressings
Discussing future surgical reconstruction
Performing his own morning care
Wearing the pressure dressings as ordered
90. Which finding indicates to the nurse that the client
understands the psychosocial impact of his severe burn
injury?
“It is normal to feel depressed.”
“I will be able to go back to work immediately.”
“I will not feel anger about my situation.”
“Once I get home, things will be normal.”
91. Which finding is characteristic during the emergent
period after a deep full thickness burn injury?
Blood pressure of 170/100 mm Hg
Foul-smelling discharge from wound
Pain at site of injury
Urine output of 10 mL/hr
92. Which is the priority nursing diagnosis during the first 24
hours for a client with chemical burns to the legs and arms
that are red in color, edematous, and without pain?
Decreased Tissue Perfusion
Disturbed Body Image
Risk for Disuse Syndrome
Risk for Ineffective Breathing Pattern
93. Which laboratory result, obtained on a client 24 hours
post-burn injury, will the nurse report to the physician
immediately?
Arterial pH, 7.32
Hematocrit, 52%
Serum potassium,7.5 mmol/L (mEq/L)
Serum sodium, 131 mmol/L (mEq/L)
94. Which nursing intervention is likely to be most helpful in
providing adequate nutrition while the client is recovering
from a thermal burn injury?
Allowing the client to eat whenever he or she wants
Beginning parenteral nutrition high in calories
Limiting calories to 3000 kcal/day
Providing a low-protein, high-fat diet
95. Which statement best exemplifies the client’s
understanding of rehabilitation after a full-thickness burn
injury?
“I am fully recovered when all the wounds are closed.”
“I will eventually be able to perform all my former activities.”
“My goal is to achieve the highest level of functioning that I
can.”
“There is never full recovery from a major burn injury.”
96. Which statement indicates that a client with facial burns
understands the need to wear a facial pressure garment?
“My facial scars should be less severe with the use of this
mask.”
“The mask will help protect my skin from sun damage.”
“This treatment will help prevent infection.”
“Using this mask will prevent scars from being permanent.”
97. The client with a dressing covering the neck is
experiencing some respiratory difficulty. What is the nurse’s
best first action?
Administer oxygen.
Loosen the dressing.
Notify the emergency team.
Document the observation as the only action.
98. During the acute phase, the nurse applied gentamicin
sulfate (topical antibiotic) to the burn before dressing the
wound. The client has all the following manifestations. Which
manifestation indicates that the client is having an adverse
reaction to this topical agent?
Increased wound pain 30 to 40 minutes after drug application
Presence of small, pale pink bumps in the wound beds
Decreased white blood cell count
Increased serum creatinine level
99. Which intervention is most important to use to prevent
infection by autocontamination in the burned client during
the acute phase of recovery?
Changing gloves between wound care on different parts of
the client’s body.
Avoiding sharing equipment such as blood pressure cuffs
between clients.
Using the closed method of burn wound management.
Using proper and consistent handwashing.
100. The burned client relates the following history of
previous health problems. Which one should alert the nurse
to the need for alteration of the fluid resuscitation plan?
Seasonal asthma
Hepatitis B 10 years ago
Myocardial infarction 1 year ago
Kidney stones within the last 6 month
Answers and Rationales
1. C. Auscultate breath sounds over the trachea and
mainstem bronchi. Difficulty swallowing and drooling
are indications of oropharyngeal edema and can
precede pulmonary failure. The client’s airway is in
severe jeopardy and intubation is highly likely to be
needed shortly.
DIF: Cognitive Level: Application or higher
TOP: Nursing Process Step: Assessment
MSC: Client Needs Category: Safe, Effective Care
Environment;
2. D. As soon as possible after resolution of the fluid
shift . Regular, progressive ambulation is initiated for
all burn clients who do not have contraindicating
concomitant injuries as soon as the fluid shift resolves.
Clients can be ambulated with extensive dressings,
open wounds, and nearly any type of attached lines,
tubing, and other equipment.
DIF: Cognitive Level: Comprehension
TOP: Nursing Process Step: Implementation/Intervention
MSC: Client Needs Category: Safe, Effective Care
Environment/Health Promotion and Maintenance;
3. C. The client’s oxygen saturation is 97%. . Clients may
have ineffective respiratory efforts and gas exchange
even though they are able to talk, have good
respiratory movement, and are alert. The best
indicator for respiratory effectiveness is the
maintenance of oxygen saturation within the normal
range.
DIF: Cognitive Level: Application or higher
TOP: Nursing Process Step: Assessment/Analysis
MSC: Client Needs Category: Safe, Effective Care
Environment/Physiological Integrity;
4. D. pain management . With a superficial partial
thickness burn such as a solar burn (sunburn), the
nurse’s main concern is pain management. Fluid
resuscitation and infection become concerns if the
burn extends to the dermal and subcutaneous skin
layers. Body image disturbance is a concern that has a
lower priority than pain management.
5. D. Vitamin D . Skin exposed to sunlight activates
vitamin D. Partial-thickness burns reduce the
activation of vitamin D. Activation of vitamin D is lost
completely in fullthickness burns.
DIF: Cognitive Level: Knowledge TOP: Nursing Process Step:
N/A
MSC: Client Needs Category: Health Promotion and
Maintenance
6. A. Applying knee splints . Applying knee splints
prevents leg contractures by holding the joints in a
position of function. Elevating the foot of the bed can’t
prevent contractures because this action doesn’t hold
the joints in a position of function. Hyperextending a
body part for an extended time is inappropriate
because it can cause contractures. Performing shoulder
range-of-motion exercises can prevent contractures in
the shoulders, but not in the legs.
7. D. Notify the burn emergency team. These findings are
associated with systemic gram-negative infection and
sepsis. This is a medical emergency and requires
prompt attention.
DIF: Cognitive Level: Application or higher
TOP: Nursing Process Step: Implementation/Intervention
MSC: Client Needs Category: Safe, Effective Care
Environment;
8. D. “My facial scars should be less severe with the use
of this mask.”. 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
change the angle of ear attachment to the head.
DIF: Cognitive Level: Application or higher
TOP: Nursing Process Step: Evaluation
MSC: Client Needs Category: Psychosocial Integrity/Health
Promotion and Maintenance
9. A. dislodge the autografts. Because exercising the
autograft sites may dislodge the grafted tissue, the
nurse should advise the client to keep the grafted
extremity in a neutral position. None of the other
options results from exercise
10. C. third-degree burn . Third-degree burn may appear
white, red, or black and are dry and leathery with no
blisters. There may be little pain because nerve
endings have been destroyed. First-degree burns are
superficial and involve the epidermis only. There is
local pain and redness but no blistering. Second-degree
burn appear red and moist with blister formation and
are painful. Fourth-degree burns involve underlying
muscle and bone tissue.
11. A. Do not apply water to the burn. Water should not
be applied to burns from lye or white phosphorus
because of the potential for an explosion or deepening
of the burn.
12. A. Increased urine output, decreased urine specific
gravity. The “fluid remobilization” phase improves
renal blood flow, increasing diuresis and restoring fluid
and electrolyte levels. The increased water content of
the urine reduces its specific gravity.
DIF: Cognitive Level: Application or higher
TOP: Nursing Process Step: Evaluation
MSC: Client Needs Category: Safe, Effective Care
Environment/Physiological Integrity;
13. B. Urine output of 20 ml/hour. A urine output of less
than 40 ml/hour in a client with burns indicates a fluid
 volume deficit. This client’s PaO2 value falls within the
normal range (80 to 100 mm Hg). White pulmonary
secretions also are normal. The client’s rectal
temperature isn’t significantly elevated and probably
results from the fluid volume deficit.
14. C. Cherry red color to the mucous membranes. The
saturation of hemoglobin molecules with carbon
monoxide and the subsequent vasodilation induces a
“cherry red” color of the mucous membranes in these
clients. The other manifestations are associated with
inhalation injury, but not specifically carbon monoxide
poisoning.
DIF: Cognitive Level: Application or higher
TOP: Nursing Process Step: Assessment
MSC: Client Needs Category: Safe, Effective Care
Environment/Physiological Integrity;
15. D. Increased serum creatinine level . Gentamicin does
not stimulate pain in the wound. The small, pale pink
bumps in the wound bed are areas of re-
epithelialization and not an adverse reaction.
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.
DIF: Cognitive Level: Application or higher
TOP: Nursing Process Step: Evaluation
MSC: Client Needs Category: Safe, Effective Care
Environment;
16. C. 31%. Using the Rule of Nine in the estimation of
total body surface burned, we allot the following: 9% –
head; 9% – each upper extremity; 18%- front chest and
abdomen; 18% – entire back; 18% – each lower
extremity and 1% – perineum.
17. A. A urine output consistently above 100 ml/hour. In a
client with burns, the goal of fluid resuscitation is to
maintain a mean arterial blood pressure that provides
adequate perfusion of vital structures. If the kidneys
are adequately perfused, they will produce an
acceptable urine output of at least 0.5 ml/kg/hour.
Thus, the expected urine output of a 155-lb client is 35
ml/hour, and a urine output consistently above 100
ml/hour is more than adequate. Weight gain from fluid
resuscitation isn’t a goal. In fact, a 4 lb weight gain in
24 hours suggests third spacing. Body temperature
readings and ECG interpretations may demonstrate
secondary benefits of fluid resuscitation but aren’t
primary indicators.
18. C. 27%
19. B. Impaired Adjustment . Recovery from a burn injury
requires a lot of work on the part of the client and
significant others. Seldom is the client restored to the
preburn level of functioning. Adjustments to changes
in appearance, family structure, employment
opportunities, role, and functional limitations are only
a few of the numerous life-changing alterations that
must be made or overcome by the client. By the
rehabilitation phase, acute pain from the injury or its
treatment is no longer a problem.
DIF: Cognitive Level: Application or higher
TOP: Nursing Process Step: Analysis
MSC: Client Needs Category: Psychosocial Integrity
20. A. range of motion. To prevent disruption of the
artificial skin’s adherence to the wound bed, the client
should restrict range of motion of the involved limb.
Protein intake and fluid intake are important for
healing and regeneration and shouldn’t be restricted.
Going outdoors is acceptable as long as the left arm is
protected from direct sunlight.
21. C. The client’s oxygen saturation is 97%. Clients may
have ineffective respiratory efforts and gas exchange
even though they are able to talk, have good
respiratory movement, and are alert. The best
indicator for respiratory effectiveness is the
maintenance of oxygen saturation within the normal
range.
DIF: Cognitive Level: Application or higher
TOP: Nursing Process Step: Assessment/Analysis
MSC: Client Needs Category: Safe, Effective Care
Environment/Physiological Integrity;
22. B. “When the burn wounds are closed.” 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 great risk
for infection as long as any area of skin is open.
DIF: Cognitive Level: Comprehension
TOP: Nursing Process Step: Implementation/Intervention
MSC: Client Needs Category: Safe, Effective Care
Environment/Health Promotion and Maintenance;
23. B. Document the finding as the only action. Decreased
or absent peristalsis is an expected response during
the emergent phase of burn injury as a result of neural
and hormonal compensation to the stress of injury. No
currently accepted intervention changes this response,
and it is not the highest priority of care at this time.
DIF: Cognitive Level: Application or higher
TOP: Nursing Process Step: Implementation/Intervention
MSC: Client Needs Category: Safe, Effective Care
Environment/Physiological Integrity;
24. D. Superficial . The characteristics of the wound meet
the criteria for a full-thickness injury (color that is
black, brown, yellow, white or red; no blisters; pain
minimal; outer layer firm and inelastic).
DIF: Cognitive Level: Application or higher
TOP: Nursing Process Step: Assessment
MSC: Client Needs Category: Safe, Effective Care
Environment/Physiological Integrity;
25. C. avoid pressure on the site . A universal concern I the
care of donor sites for burn care is to keep the site
away from sources of pressure. Ventilation of the site
and keeping the site fully covered are practices in
some institutions but aren’t hallmarks of donor site
care. Placing the site in a position of dependence isn’t
a justified aspect of donor site care.
26. B. Serum potassium 7.5 mmol/L (mEq/L) . All these
findings are abnormal; however, only the serum
potassium level is changed to the degree that serious,
life-threatening responses could result. With such a
rapid rise in the potassium level, the client is at high
risk for experiencing severe cardiac dysrhythmias and
death.
DIF: Cognitive Level: Application or higher
TOP: Nursing Process Step: Assessment/Analysis
MSC: Client Needs Category: Safe, Effective Care
Environment;
27. C. The burned areas include the hands and
perineum.Burns of the perineum increase the risk for
 sepsis. Burns of the hands require special attention to
ensure the best functional outcome.
DIF: Cognitive Level: Comprehension TOP: Nursing Process
Step: Assessment
MSC: Client Needs Category: Physiological Integrity/Safe,
Effective Care Environment;
28. D. Hip at zero flexion with leg flat . Maximum function
for ambulation occurs when the hip and leg are
maintained at full extension with neutral rotation.
Although the client does not have to spend 24 hours at
a time in this position, he or she should be in this
position (in bed or standing) more of the time than
with the hip in any degree of flexion.
DIF: Cognitive Level: Application or higher
TOP: Nursing Process Step: Implementation/Intervention
MSC: Client Needs Category: Safe, Effective Care
Environment/Health Promotion and Maintenance;
29. A. Handwashing on entering the client’s room .Cross-
contamination occurs when microorganisms from
another person or the environment are transferred to
the client. Although all the interventions listed above
can help reduce the risk for infection, only
handwashing can prevent crosscontamination.
DIF: Cognitive Level: Application or higher
TOP: Nursing Process Step: Implementation/Intervention
MSC: Client Needs Category: Safe, Effective Care
Environment;
30. B. Document the finding as the only action. 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.
DIF: Cognitive Level: Application or higher
TOP: Nursing Process Step: Implementation/Intervention
MSC: Client Needs Category: Safe, Effective Care
Environment;
31. D. Related to circumferential eschar. As edema
develops on circumferential burns, eschar forms a
tight, constricting band, compromising circulation to
the extremity distal to the circumferential site and
impairing physical mobility. This client isn’t likely to
develop fat emboli unless long bone or pelvic fractures
are present. Infection doesn’t alter physical mobility. A
client with burns on the lower portions of both legs
isn’t likely to have femoral artery occlusion.
32. C. “Apply sunscreen even on overcast days.” Sunscreen
should be applied even on overcast days, because the
sun’s rays are as damaging then as on sunny days. The
sun is strongest from 10 a.m. to 2 p.m. (11 a.m. to 3
p.m. daylight saving time) — not from 1 to 4 p.m. Sun
exposure should be minimized during these hours. The
nurse should recommend sunscreen with a sun
protection factor of at least 15. Sitting in the shade
when at the beach doesn’t guarantee protection
against sunburn because sand, concrete, and water can
reflect more than half the sun’s rays onto the skin.
33. D. Hoarseness of the voice . Hoarseness indicate injury
to the respiratory system and could indicate the need
for immediate intubation. Thirst following burns is
expected because of the massive fluid shifts and
resultant loss leading to dehydration. Pain, either
severe or moderate, is expected with a burn injury.
The client’s output is adequate.
34. C. Capillary refill is slow in the digits and the distal
pulse is absent. Circumferential eschar can act as a
tourniquet when edema forms from the fluid shift,
increasing tissue pressure and preventing blood flow
to the distal extremities and increasing the risk for
tissue necrosis. This problem is an emergency and,
without intervention, can lead to loss of the distal
limb. This problem can be reduced or corrected with
an escharotomy.
DIF: Cognitive Level: Comprehension TOP: Nursing Process
Step: Evaluation
MSC: Client Needs Category: Safe, Effective Care
Environment;
35. A. Fluid shift . Intense pain and carbon monoxide
poisoning increase blood pressure. Hemorrhage is
unusual in a burn injury. The physiologic effect of
histamine release in injured tissues is a loss of vascular
volume to the interstitial space, with a resulting
decrease in blood pressure.
DIF: Cognitive Level: Comprehension TOP: Nursing Process
Step: Assessment
MSC: Client Needs Category: Physiological Integrity/Safe,
Effective Care Environment;
36. B. Loosen the dressing. Respiratory difficulty can arise
from external pressure. The first action in this situation
would be to loosen the dressing and then reassess the
client’s respiratory status.
DIF: Cognitive Level: Application or higher
TOP: Nursing Process Step: Implementation/Intervention
MSC: Client Needs Category: Safe, Effective Care
Environment/Physiological Integrity;
37. C. Have the client turn the head from side to side 90
degrees every hour while awake. The function that
would be disrupted by a contracture to the posterior
neck is flexion. Moving the head from side to side
prevents such a loss of flexion.
DIF: Cognitive Level: Application or higher
TOP: Nursing Process Step: Implementation/Intervention
MSC: Client Needs Category: Health Promotion and
Maintenance/Safe, Effective Care Environment;
38. C. “To decrease hydrochloric acid production in the
stomach and prevent ulcers.” Ulcerative
gastrointestinal disease may develop within 24 hours
after a severe burn as a result of increased
hydrochloric acid production and decreased mucosal
barrier. Cimetidine inhibits the production and release
of hydrochloric acid.
Cognitive Level: Application or higher
TOP: Nursing Process Step: Implementation/Intervention
MSC: Client Needs Category: Safe, Effective Care
Environment/Health Promotion and Maintenance;
39. D. Circulatory status . During the acute phase of a
burn, the nurse should assess the client’s circulatory
and respiratory status, vital signs, fluid intake and
output, ability to move, bowel sounds, wounds, and
mental status. Information about the client’s lifestyle
and alcohol and tobacco use may be obtained later
when the client’s condition has stabilized.
40. C. During fluid remobilization . Hypokalemia is most
likely to occur during the fluid remobilization period as
a result of dilution, potassium movement back into the
 cells, and increased potassium excreted into the urine
with the greatly increased urine output.
DIF: Cognitive Level: Comprehension TOP: Nursing Process
Step: Assessment
MSC: Client Needs Category: Safe, Effective Care
Environment;
41. C. Myocardial infarction 1 year ago . It is likely the
client has a diminished cardiac output as a result of the
old MI and would be at greater risk for the
development of congestive heart failure and
pulmonary edema during fluid resuscitation.
DIF: Cognitive Level: Comprehension TOP: Nursing Process
Step: Assessment
MSC: Client Needs Category: Safe, Effective Care
Environment/Physiological Integrity;
42. B. “Because the graft is my own skin, there is no
chance it won’t ‘take’.” Factors other than tissue type,
such as circulation and infection, influence whether
and how well a graft “takes.” The client should be
prepared for the possibility that not all grafting
procedures will be successful.
DIF: Cognitive Level: Application or higher
TOP: Nursing Process Step: Evaluation
MSC: Client Needs Category: Health Promotion and
Maintenance/Psychosocial Integrity
43. C. The danger of an overdose during fluid
remobilization is reduced. Although providing some
pain relief has a high priority, and giving the drug by
the IV route instead of IM, SC, or orally does increase
the rate of effect, the most important reason is to
prevent an overdose from accumulation of drug in the
interstitial space during the fluid shift of the emergent
phase. When edema is present, cumulative doses are
rapidly absorbed when the fluid shift is resolving. This
delayed absorption can result in lethal blood levels of
analgesics.
DIF: Cognitive Level: Comprehension
TOP: Nursing Process Step: Implementation/Intervention
MSC: Client Needs Category: Safe, Effective Care
Environment;
44. D. “In what exact place or space were you when you
were burned?” The risk for inhalation injury is greatest
when flame burns occur indoors in small, poorly
ventilated rooms. although smoking increases the risk
for some problems, it does not predispose the client
for an inhalation injury.
DIF: Cognitive Level: Application or higher
TOP: Nursing Process Step: Assessment
MSC: Client Needs Category: Safe, Effective Care
Environment;
45. D. Hemoglobin S electrophoresis . Sickle cell disease
and sickle cell trait are more common among African
Americans. Although clients with sickle cell disease
usually know their status, the client with sickle cell
trait may not. The fluid, circulatory, and respiratory
alterations that occur in the emergent phase of a burn
injury could result in decreased tissue perfusion that is
sufficient to cause sickling of cells, even in a person
who only has the trait. Determining the client’s sickle
cell status by checking the percentage of hemoglobin S
is essential for any African American client who has a
burn injury.
DIF: Cognitive Level: Comprehension TOP: Nursing Process
Step: Assessment
MSC: Client Needs Category: Safe, Effective Care
Environment/Health Promotion and Maintenance;
46. A. A urine output consistently above 100 ml/hour. In a
client with burns, the goal of fluid resuscitation is to
maintain a mean arterial blood pressure that provides
adequate perfusion of vital structures. If the kidneys
are adequately perfused, they will produce an
acceptable urine output of at least 0.5 ml/kg/hour.
Thus, the expected urine output of a 155-lb client is 35
ml/hour, and a urine output consistently above 100
ml/hour is more than adequate. Weight gain from fluid
resuscitation isn’t a goal. In fact, a 4-lb weight gain in
24 hours suggests third spacing. Body temperature
readings and ECG interpretations may demonstrate
secondary benefits of fluid resuscitation but aren’t
primary indicators.
47. D. Fluid shift from intravascular space to the interstitial
space. This period is the burn shock stage or the
hypovolemic phase. Tissue injury causes vasodilation
that results in increase capillary permeability making
fluids shift from the intravascular to the interstitial
space. This can lead to a decrease in circulating blood
volume or hypovolemia which decreases renal
perfusion and urine output.
48. C. The “bands” outnumber the “segs.” Normally, the
mature segmented neutrophils (“segs”) are the major
population of circulating leukocytes, constituting 55%
to 70% of the total white blood count. Fewer than 3%
to 5% of the circulating white blood cells should be the
less mature “band” neutrophils. A left shift occurs
when the bone marrow releases more immature
neutrophils than mature neutrophils. Such a shift
indicates severe infection or sepsis, in which the
client’s immune system cannot keep pace with the
infectious process.
DIF: Cognitive Level: Application or higher
TOP: Nursing Process Step: Assessment
MSC: Client Needs Category: Safe, Effective Care
Environment/Health Promotion and Maintenance;
49. C. Partial-thickness superficial . The characteristics of
the wound meet the criteria for a superficial
partialthickness injury (color that is pink or red;
blisters; pain present and high).
DIF: Cognitive Level: Application or higher
TOP: Nursing Process Step: Assessment
MSC: Client Needs Category: Safe, Effective Care
Environment/Physiological Integrity;
50. B. Heart rate and rhythm . The airway is not at any
particular risk with this injury. Electric 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, rhythm, and ECG changes.
DIF: Cognitive Level: Application or higher
TOP: Nursing Process Step: Assessment
MSC: Client Needs Category: Safe, Effective Care
Environment;
51. B. Notify the emergency team. 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. The client requires the
establishment of an emergency airway and the
swelling usually precludes intubation.
DIF: Cognitive Level: Application or higher
TOP: Nursing Process Step: Implementation/Intervention
MSC: Client Needs Category: Safe, Effective Care
Environment;
52. D. “I will be fully recovered when I achieve the highest
possible level of functioning that I can.” 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.
DIF: Cognitive Level: Application or higher
TOP: Nursing Process Step: Evaluation
MSC: Client Needs Category: Psychosocial Integrity
53. D. 36% . The Rule of Nines divides body surface area
into percentages that, when totaled, equal 100%.
According to the Rule of Nines, the arms account for
9% each, the anterior legs account for 9% each, and
the anterior trunk accounts for 18%. Therefore, this
client’s burns cover 36% of the body surface area.
54. C. Frequently observing for hoarseness, stridor, and
dyspnea . Burns located in the upper torso, especially
resulting from thermal injury related to fires can lead
to inhalation burns. This causes swelling of the
respiratory mucosa and blistering which can lead to
airway obstruction manifested by hoarseness, noisy
and difficult breathing. Maintaining a patent airway is
a primary concern.
55. D. Helping the client to rest in the position of maximal
comfort . Mobility and placing the burned areas in
their functional position can help prevent contracture
deformities related to burns. Pain can immobilize a
client as he seeks the position where he finds less pain
and provides maximal comfort. But this approach can
lead to contracture deformities and other
complications.
56. A. Changing gloves between wound care on different
parts of the client’s body. Autocontamination is the
transfer of microorganisms from one area to another
area of the same client’s 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
difference parts of the client’s body can prevent
autocontamination.
DIF: Cognitive Level: Application or higher
TOP: Nursing Process Step: Implementation/Intervention
MSC: Client Needs Category: Safe, Effective Care
Environment/Physiological Integrity;
57. B. Crystalloids . Although not universally true, most
fluid resuscitation for burn injuries starts with
crystalloid solutions, such as normal saline and
Ringer’s lactate. The burn client rarely requires blood
during the emergent phase unless the burn is
complicated by another injury that involved
hemorrhage. Colloids and plasma are not generally
used during the fluid shift phase because these large
particles pass through the leaky capillaries into the
interstitial fluid, where they increase the osmotic
pressure. Increased osmotic pressure in the interstitial
fluid can worsen the capillary leak syndrome and make
maintaining the circulating fluid volume even more
difficult.
DIF: Cognitive Level: Comprehension
TOP: Nursing Process Step: Implementation/Intervention
MSC: Client Needs Category: Safe, Effective Care
Environment;
58. D. fluid and electrolyte monitoring . Total parenteral
nutrition is a method of providing nutrients to the
body by an IV route. The admixture is made up of
proteins, carbohydrates, fats, electrolytes, vitamins,
trace minerals and sterile water based on individual
client needs. It is intended to improve the clients
nutritional status. Because of its composition, it is
important to monitor the clients fluid intake and
output including electrolytes, blood glucose and
weight.
59. A. Ineffective airway clearance related to edema of the
respiratory passages . When caring for a client with
upper torso burns, the nurse’s primary goal is to
maintain respiratory integrity. Therefore, option A
should take the highest priority.
60. C. Risk for Disuse Syndrome . During the emergent
phase, fluid shifts into interstitial tissue in burned
areas. When the burn is circumferential on an
extremity, the swelling can compress blood vessels to
such an extent that circulation is impaired distal to the
injury, necessitating the intervention of an
escharotomy. Chemical burns do not cause inhalation
injury.
DIF: Cognitive Level: Application or higher
TOP: Nursing Process Step: Analysis
MSC: Client Needs Category: Safe, Effective Care
Environment;
61. C. Learning to perform dressing changes. 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 the
other distractors are important in the rehabilitation
stage. However, dressing changes have priority.
62. A. Begin intravenous fluids. Hypovolemic shock is a
common cause of death in the emergent phase of
clients with serious injuries. Fluids can treat this
problem. An ECG and CBC will be taken to ascertain if 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.
63. D. Place the client in an upright position. Pulmonary
edema can result from fluid resuscitation given for
burn treatment. This can occur even in a young healthy
person. Placing the client in the upright position can
relieve the lung congestion immediately before other
measures can be carried out. Digoxin may be given
later to increase cardiac contractility to prevent backup
of fluid into the lungs. Chest physiotherapy will not get
rid of fluid. Monitoring urine output is important.
However it is not an immediate intervention.
64. A. Have the client turn the head from side to side. The
function that would be disrupted by a contracture to
the posterior neck is flexion. Moving the head from
side to side prevents such a loss of flexion. The other
 distractors listed do not call for moving of the head
from side to side. This movement is what would
prevent contractures from occurring.
65. D. Preparing for intubation. 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. The client requires the
establishment of an emergency airway. The swelling
usually precludes intubation.
66. A. Documents the finding. Neural and hormonal
compensation to the stress of the burn injury in the
emergent phase increase 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 make her more of a 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.
67. B. Partial-thickness superficial. The characteristics of
the wound meet the criteria for a superficial partial-
thickness injury: color that is pink or red; blisters and
pain present. Blisters are not seen with full-thickness
and superficial burns, and are rarely seen with deep
partial-thickness burns. Deep partial-thickness burns
are red to white in color.
68. A. Full-thickness. The characteristics of the wounds
meet the criteria for a full-thickness injury: color that is
black, brown, yellow, white, or red; no blisters; pain
minimal; outer layer firm and inelastiC. Partial-
thickness superficial burns appear pink to red in color,
with pain. Partial-thickness burn color is deep red to
white in color with pain, and superficial burn color is
pink to red, with pain.
69. B. Heart rate and rhythm. The airway is not at any
particular risk with this injury. Therefore, respiratory
rate and pulse oximetry are not priority assessments.
Electric 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,
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.
70. B. Hip at zero flexion with leg flat. Maximum function
for ambulation occurs when the hip and 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.
71. C. Auscultates breath sounds over the trachea and
mainstem bronchi. 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. The 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 to assess oxygenation to
the brain. Ascertaining time of last food intake is
important in case intubation is necessary (the nurse
would be more alert for the 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.
72. C. Impaired Adjustment. Recovery from a burn injury
requires a lot of work on the part of the client and
significant others. The client is seldom restored to his
or her preburn level of functioning. Adjustments to
changes in appearance, family structure, employment
opportunities, role, and functional limitations are only
a few of the numerous life-changing alterations that
must be made or overcome by the client. By the
rehabilitation phase, acute pain from the injury or its
treatment is no longer a problem.
73. C. “This will help prevent stomach ulcers.” Ulcerative
gastrointestinal disease may develop within 24 hours
after a severe burn as a result of increased
hydrochloric acid production and 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,
prevent hypovolemic shock, or prevent kidney
damage.
74. C. “You will not look exactly the same.” Many clients
have unrealistic expectations of reconstructive surgery
and envision an appearance identical or equal in
quality to the preburn state. Pressure dressings
prevent further scarring. They cannot remove scars.
The client and family should be taught the expected
cosmetic outcomes.
75. D. Preparing to do a workup for sepsis. 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
if the client has sepsis and treating it before it becomes
a shock situation. Increasing the rate of intravenous
fluids may be done to replace fluid losses with
diarrhea, but is not the priority action.
76. D. “When the burn wounds are closed.” 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.
77. B. Keep a smoke detector in each bedroom. Everyone
should use smoke detectors and carbon monoxide
detectors in their home environment (just not in a
garage). Recommendations are that each bedroom
have a separate smoke detector. Space heaters can be
a cause of fire if clothing, bedding, and other
flammable objects are nearby.
78. D. Removes loose nonviable tissue. All steps are part of
the nonsurgical wound care for clients with burn
injuries. The first step in this process is removing
exudates and necrotic tissue.
79. D. Use of space heaters. Minor burns are common
occurrences. The use of space heaters can cause a fire
if clothing, bedding and other flammable objects are
near them. Chimneys should be swept each year to
prevent creosote build-up and resultant fire. Burn
injuries do not commonly occur from microwave
cooking, but rather when taking food from this oven.
Lastly, sunscreen agents are recommended to prevent
sunburn.
80. A. Creatinine. 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 sodium or magnesium level.
81. D. Wash hands on entering the client’s room. Infection
can occur when microorganisms from another person
or the environment are transferred to the client.
Although all the interventions listed can help reduce
the risk for infection, hand washing is the most
effective technique for preventing infection
transmission.
82. D. Wound infection . Color change, purulent, foul-
smelling drainage, increased white blood cell count,
and fever could all indicate infection. These symptoms
will not be seen in the acute phase of the injury.
Autodigestion of collagen and granulation of tissue will
not increase the body temperature or cause foul-
smelling wound discharge.
83. B. Documents the finding. Decreased or absent
peristalsis is an expected response during the
emergent phase of burn injury as a result of neural and
hormonal compensation to the stress of injury. No
currently accepted intervention changes this response.
It is not the highest priority of care at this time.
84. A. Administering morphine 4 mg intravenously. Drug
therapy for pain management requires opioid and
nonopioid analgesics. The IV route is used because of
problems with absorption from the muscle and
stomach. Tactile stimulation can be used for pain
management. For the client to avoid shivering, the
room must be kept warm and heat should be applied.
85. A. “Because the graft is my own skin, there is no
chance it won’t ‘take.’” 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. The donor sites will be
painful after the surgery, there can be scarring in the
area where skin is removed for grafting, and the client
is still at risk for infection.
86. B. Changing gloves between wound care on different
parts of the client’s body. Autocontamination is the
transfer of microorganisms from one area to another
area of the same client’s 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 client’s body can prevent
autocontamination.
87. A. Brassy cough. Brassy cough and wheezing are some
signs seen with inhalation injury. All the other
symptoms are seen with carbon monoxide poisoning.
88. D. Urine output = 50 mL/hr. The fluid remobilization
phase improves renal blood flow, increases diuresis,
and restores blood pressure and heart rate to more
normal levels, as well as laboratory values.
89. C. Performing his own morning care. Indicators that
the client with a burn injury has a positive perception
of his appearance includes the 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 increase self-perception.
90. A. “It is normal to feel depressed.” 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. Feelings of 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.
91. D. Urine output of 10 mL/hr. During the fluid shift of
the emergent period, blood flow to the kidney may not
be adequate for glomerular filtration. As a result, urine
output is greatly decreaseD. Foul-smelling discharge
does not occur during the emergent phase and blood
pressure is usually low. Pain does not occur with deep
full-thickness burns.
92. A. Decreased Tissue Perfusion. During the emergent
phase, fluid shifts into interstitial tissue in burned
areas. When the burn is circumferential on an
extremity, the swelling can compress blood vessels to
such an extent that circulation is impaired distal to the
injury, causing decreased tissue perfusion and
necessitating the intervention of an escharotomy.
Chemical burns do not cause inhalation injury and a
disrupted breathing pattern. Disturbed body image
and disuse syndrome can develop. However, these are
not priority diagnoses at this time.
93. C. Serum potassium,7.5 mmol/L (mEq/L). The serum
potassium level is changed to the degree that serious
life-threatening responses could result. With such a
rapid rise in the potassium level, the client is at high
risk for experiencing severe cardiac dysrhythmias and
death. All the other findings are abnormal, but not to
the same degree of severity, and would be expected in
the emergent phase after a burn injury.
94. A. Allowing the client to eat whenever he or she
wants. Clients should request food whenever they
think that they can eat, not just according to the
hospital’s standard meal schedule. The nurse needs to
work with a nutritionist 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. Parenteral nutrition may be given as a last
resort because it is invasive and can lead to infectious
and metabolic complications.
95. C. “My goal is to achieve the highest level of
functioning that I can.” Although a return to pre-burn
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.
96. A. “My facial scars should be less severe with the use
of this mask.” 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
for wearing the mask. The pressure garment will not
alter the risk for infection.
97. B. Loosen the dressing. Respiratory difficulty can arise
from external pressure. The first action in this situation
would be to loosen the dressing and then reassess the
client’s respiratory status.
98. D. Increased serum creatinine level . Gentamicin does
not stimulate pain in the wound. The small, pale pink
bumps in the wound bed are areas of re-
epithelialization and not an adverse reaction.
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.
99. A.Changing gloves between wound care on different
parts of the client’s body. Autocontamination is the
transfer of microorganisms from one area to another
area of the same client’s 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 client’s body can prevent
autocontamination.
100. C. Myocardial infarction 1 year ago. It is likely the
client has a diminished cardiac output as a result of the
old MI and would be at greater risk for the
development of congestive heart failure and
pulmonary edema during fluid resuscitation.
Dermatitis 15 items
1) A female adult client with atopic dermatitis is prescribed a
potent topical corticosteroid, to be covered with an occlusive
dressing. To address a potential client problem associated
with this treatment, the nurse formulates the nursing
diagnosis of Risk for injury. To complete the nursing diagnosis
statement, the nurse should add which “related-to” phrase?
Related to potential interactions between the topical
corticosteroid and other prescribed drugs
Related to vasodilatory effects of the topical corticosteroid
Related to percutaneous absorption of the topical
corticosteroid
Related to topical corticosteroid application to the face, neck,
and intertriginous sites
2) In the past, doctors thought which of these caused atopic
dermatitis?
Too much sun
An emotional disorder
Food allergies
None of the above
3) Nurse Bea plans to administer dexamethasone cream to a
client who has dermatitis over the anterior chest How should
the nurse apply this topical agent?
With a circular motion, to enhance absorption
With an upward motion, to increase blood supply to the
affected area
In long, even, outward, and downward strokes in the
direction of hair growth
In long, even, outward, and upward strokes in the direction
opposite hair growth
4) A female client with atopic dermatitis is prescribed
medication for photochemotherapy. The nurse teaches the
client about the importance of protecting the skin from
ultraviolet light before drug administration and for 8 hours
afterward and stresses the need to protect the eyes. After
administering medication for photochemotherapy, the client
must protect the eyes for:
4 hours.
8 hours.
24 hours.
48 hours.
5) A 5-month-old is diagnosed with atopic dermatitis. Nursing
interventions will focus on:
Preventing infection
Administering antipyretics
Keeping the skin free of moisture
Limiting oral fluid intake
6) People who have atopic dermatitis also may have:
Asthma
Allergies
Acne
A and B
7) A 28 yr-old nurse has complaints of itching and a rash of
both hands. Contact dermatitis is initially suspected. The
diagnosis is confirmed if the rash appears:
erythematous with raised papules
dry and scaly with flaking skin
inflamed with weeping and crusting lesions
excoriated with multiple fissures
8) Which of the following measures would be appropriate for
the nurse to teach the parent of a nine month-old infant
about diaper dermatitis?
Use only cloth diapers that are rinsed in bleach
Do not use occlusive ointments on the rash
Use commercial baby wipes with each diaper change
Discontinue a new food that was added to the infant’s diet
just prior to the rash
9) Atopic dermatitis is also often called:
Acne
Eczema
Psoriasis
Pimples
10) When the nurse observes diffuse swelling involving the
deeper skin layers in the patient who has experienced an
allergic reaction, the nurse records the finding as
angioneurotic edema. 4. D. 48 hours. To prevent eye discomfort, the client must
urticaria. protect the eyes for 48 hours after taking medication
contact dermatitis. for photochemotherapy. Protecting the eyes for a
pitting edema. shorter period increases the risk of eye injury.
11) One characteristic of atopic dermatitis is: 5. A. Preventing infection . The nurse should prevent the
infant with atopic dermatitis (eczema) from scratching,
It affects the face more than the rest of the body which can lead to skin infections. Answer B is incorrect
It can leave pockmarks on the skin because fever is not associated with atopic dermatitis.
It cycles through periods of flares and remissions Answers C and D are incorrect because they increase
It is worse in autumn dryness of the skin, which worsens the symptoms of
12) Which nutrient deficiency is associated with the atopic dermatitis.
development of Pellagra, Dermatitis and Diarrhea? 6. D. A and B
7. A. erythematous with raised papules . Contact
Vitamin B1 dermatitis is caused by exposure to a physical or
Vitamin B2 chemical allergen, such as cleaning products, skin care
Vitamin B3 products, and latex gloves. Initial symptoms of itching,
Vitamin B6 erythema, and raised papules occur at the site of the
13) What is caused by exposure to an allergen or by direct exposure and can begin within 1 hour of exposure.
chemical or mechanical irritation of the skin followed by a Allergic reactions tend to be red and not scaly or flaky.
subsequent exposure rash? Weeping, crusting lesions are also uncommon unless
the reaction is quite severe or has been present for a
Contact dermatitis long time. Excoriation is more common in skin
Scleroderma disorders associated with a moist environment.
14) Which group of people is more likely to develop atopic 8. D. Discontinue a new food that was added to the
dermatitis? infant’s diet just prior to the rash. The addition of new
foods to the infant”s diet may be a cause of diaper
Infants and young children dermatitis.
Teenagers 9. B. Eczema . Eczema is a general term for many types of
Adults 20 to 49 dermatitis (inflammation of the skin). Atopic
Older adults dermatitis is the most common type of eczema. Acne is
15) A contraindication for topical corticosteroid usage in a a different kind of skin disease; pimples are a symptom
male patient with atopic dermatitis (eczema) is: of acne. Like eczema, psoriasis is a chronic skin disease,
but it is caused by a different disorder of the immune
Parasite infection. system.
Viral infection. 10. A. angioneurotic edema. The area of skin
Bacterial infection. demonstrating angioneurotic edema may appear
Spirochete infection. normal but often has a reddish hue and does not pit.
11. C. It cycles through periods of flares and remissions .
Answers and Rationales When the condition worsens, that period is called a
1. C. Related to percutaneous absorption of the topical flare or exacerbation. When it improves or clears up
corticosteroid. A potent topical corticosteroid may entirely, that period is called a remission. In some
increase the client’s risk for injury because it may be people, this cycle of flares and remissions may be
absorbed percutaneously, causing the same adverse seasonal.
effects as systemic corticosteroids. Topical 12. C. Vitamin B3
corticosteroids aren’t involved in significant drug 13. A. Contact dermatitis
interactions. These preparations cause 14. A. Infants and young children . Sixty-five percent of
vasoconstriction, not vasodilation. A potent topical patients with atopic dermatitis develop symptoms in
corticosteroid rarely is prescribed for use on the face, the first year of life, and 90 percent develop symptoms
neck, or intertriginous sites because application on before the age of 5. Atopic dermatitis can go into
these areas may lead to increased adverse effects. permanent remission by the time a child reaches
2. B. An emotional disorder. Today, medical experts adulthood. In about 60 percent of cases, however, it
know stress can make the disease worse, but stress continues into adulthood. Occasionally, it shows up for
does not cause it. Atopic dermatitis appears to result the first time later in life. In adults, atopic dermatitis
from a combination of genetic and environmental can show up after the skin is exposed to harsh
factors. It is not contagious and can’t be passed from conditions.
one person to another. 15. B. Viral infection. Topical agents produce a localized,
3. C. In long, even, outward, and downward strokes in rather than systemic effect. When treating atopic
the direction of hair growth. When applying a topical dermatitis with a steroidal preparation, the site is
agent, the nurse should begin at the midline and use vulnerable to invasion by organisms. Viruses, such as
long, even, outward, and downward strokes in the herpes simplex or varicella-zoster, present a risk of
direction of hair growth. This application pattern disseminated infection. Educate the patient using
reduces the risk of follicle irritation and skin topical corticosteroids to avoid crowds or people
inflammation. known to have infections and to report even minor
signs of an infection. Topical corticosteroid usage
results in little danger of concurrent infection with
these agents.