50 item integumentary exam with answers and rationale A+ GRADED

50 item Integumentary Exam Source: Saunders Q&A NCLEX Review 3rd edition 1. A nurse is caring for a burn client who has sustained thoracic burns and smoke inhalation and is risk for impaired gas exchange. The nurse avoids which action in caring for this client? a. repositioning the client from side to side every 2 hours b. maintaining the client in a supine position with the head of the bed elevated c. suctioning the airway as needed d. providing humidified oxygen as prescribed Aggressive pulmonary measures are used to prevent respiratory complications in the client who has impaired gas exchange as a result of a burn injury. These include turning and repositioning, positioning for comfort, using humidified oxygen, providing incentive spirometry, and suctioning the client on an as needed basis. The nurse would avoid maintaining the client in one position. This will ultimately lead to atelectasis and possible pneumonia. 2. A client sustains a burn injury to the entire right arm, entire right leg, and anterior thorax. According to the rule of nine’s the nurse determines that what body percent was injured? Answer: ______________45%________________________ According to the Rule of Nine’s, the right arm is equal to 9% and the left arm is equal to 9%. The right leg is equal to 18% and the left leg is equal to 18%. The anterior thorax is equal to 18% and the posterior thorax is equal to 18%. The head is equal to 9% and the perineum is 1%. If the anterior thorax (18%), entire right leg (18%), and entire right arm (9%) were burned, according to the Rule of Nine’s, this would equal 45%.