NURS4500 Final Exam Skin correctly
answered already passed
The client comes into the emergency room in severe pain and reports that a pot of boiling hot
water accidentally spilled on his lower legs. The assessment reveals blistered, mottled red skin,
and both feet are edematous. Which depth of burn should the nurse document?
1. Superficial partial thickness.
2. Deep partial thickness.
3. Full thickness.
4. First degree. - correct answer ✔✔2. Deep partial thickness.
The client with full-thickness burns to 40% of the body, including both legs, is being transferred
from a community hospital to a burn center. Which measure should be instituted before the
transfer?
1. A 22-gauge intravenous line with normal saline infusing.
2. Wounds covered with moist sterile dressings.
3. No intravenous pain medication.
4. Adequate peripheral circulation to both feet ensured. - correct answer ✔✔4. Adequate
peripheral circulation to both feet ensured.
The client has full-thickness burns to 65% of the body, including the chest area. After
establishing a patent airway, which collaborative intervention is priority for the client?
1. Replace fluids and electrolytes.
2. Prevent contractures of extremities.
,3. Monitor urine output hourly.
4. Prepare to assist with an escharotomy. - correct answer ✔✔1. Replace fluids and electrolytes.
The nurse is applying mafenide acetate (Sulfamylon), a sulfa antibiotic cream, to a
client's lower extremity burn. Which assessment data would require immediate attention by the
nurse?
1. The client complains of pain when the medication is administered.
2. The client's potassium level is 3.9 mEq/L and sodium level is 137 mEq/L.
3. The client's ABGs are pH 7.34, PaO2 98, PaCO2 38, and HCO3 20.
4. The client is able to perform active range-of-motion exercises. - correct answer ✔✔3. The
client's ABGs are pH 7.34, PaO2 98, PaCO2 38, and HCO3 20.
The client is scheduled to have a xenograft to a left lower-leg burn. The client asks the nurse,
"What is a xenograft?" Which statement by the nurse would be the best response?
1. "The doctor will graft skin from your back to your leg."
2. "The skin from a donor will be used to cover your burn."
3. "The graft will come from an animal, probably a pig."
4. "I think you should ask your doctor about the graft." - correct answer ✔✔3. "The graft will
come from an animal, probably a pig."
The intensive care unit (ICU) burn nurse is developing a nursing care plan for a client with severe
full-thickness and deep partial-thickness burns over half the body. Which client problem has
priority?
1. High risk for infection.
2. Ineffective coping.
, 3. Impaired physical mobility.
4. Knowledge deficit. - correct answer ✔✔1. High risk for infection.
The nurse writes the nursing diagnosis "impaired skin integrity related to open burn wounds."
Which intervention would be appropriate for this nursing diagnosis?
1. Provide analgesia before pain becomes severe.
2. Clean the client's wounds, body, and hair daily.
3. Screen visitors for respiratory infections.
4. Encourage visitors to bring plants and flowers. - correct answer ✔✔2. Clean the client's
wounds, body, and hair daily.
Which nursing interventions should be included for the client who has full-thickness and deep
partial-thickness burns to 50% of the body? Select all that apply.
1. Perform meticulous hand hygiene.
2. Use sterile gloves for wound care.
3. Wear gown and mask during procedures.
4. Change invasive lines once a week.
5. Administer antibiotics as prescribed. - correct answer ✔✔1. Perform meticulous hand
hygiene.
The nurse is caring for a client with deep partial-thickness and full-thickness burns
to the chest area. Which assessment data would warrant notifying the health-care
provider?
1. The client is complaining of severe pain.
answered already passed
The client comes into the emergency room in severe pain and reports that a pot of boiling hot
water accidentally spilled on his lower legs. The assessment reveals blistered, mottled red skin,
and both feet are edematous. Which depth of burn should the nurse document?
1. Superficial partial thickness.
2. Deep partial thickness.
3. Full thickness.
4. First degree. - correct answer ✔✔2. Deep partial thickness.
The client with full-thickness burns to 40% of the body, including both legs, is being transferred
from a community hospital to a burn center. Which measure should be instituted before the
transfer?
1. A 22-gauge intravenous line with normal saline infusing.
2. Wounds covered with moist sterile dressings.
3. No intravenous pain medication.
4. Adequate peripheral circulation to both feet ensured. - correct answer ✔✔4. Adequate
peripheral circulation to both feet ensured.
The client has full-thickness burns to 65% of the body, including the chest area. After
establishing a patent airway, which collaborative intervention is priority for the client?
1. Replace fluids and electrolytes.
2. Prevent contractures of extremities.
,3. Monitor urine output hourly.
4. Prepare to assist with an escharotomy. - correct answer ✔✔1. Replace fluids and electrolytes.
The nurse is applying mafenide acetate (Sulfamylon), a sulfa antibiotic cream, to a
client's lower extremity burn. Which assessment data would require immediate attention by the
nurse?
1. The client complains of pain when the medication is administered.
2. The client's potassium level is 3.9 mEq/L and sodium level is 137 mEq/L.
3. The client's ABGs are pH 7.34, PaO2 98, PaCO2 38, and HCO3 20.
4. The client is able to perform active range-of-motion exercises. - correct answer ✔✔3. The
client's ABGs are pH 7.34, PaO2 98, PaCO2 38, and HCO3 20.
The client is scheduled to have a xenograft to a left lower-leg burn. The client asks the nurse,
"What is a xenograft?" Which statement by the nurse would be the best response?
1. "The doctor will graft skin from your back to your leg."
2. "The skin from a donor will be used to cover your burn."
3. "The graft will come from an animal, probably a pig."
4. "I think you should ask your doctor about the graft." - correct answer ✔✔3. "The graft will
come from an animal, probably a pig."
The intensive care unit (ICU) burn nurse is developing a nursing care plan for a client with severe
full-thickness and deep partial-thickness burns over half the body. Which client problem has
priority?
1. High risk for infection.
2. Ineffective coping.
, 3. Impaired physical mobility.
4. Knowledge deficit. - correct answer ✔✔1. High risk for infection.
The nurse writes the nursing diagnosis "impaired skin integrity related to open burn wounds."
Which intervention would be appropriate for this nursing diagnosis?
1. Provide analgesia before pain becomes severe.
2. Clean the client's wounds, body, and hair daily.
3. Screen visitors for respiratory infections.
4. Encourage visitors to bring plants and flowers. - correct answer ✔✔2. Clean the client's
wounds, body, and hair daily.
Which nursing interventions should be included for the client who has full-thickness and deep
partial-thickness burns to 50% of the body? Select all that apply.
1. Perform meticulous hand hygiene.
2. Use sterile gloves for wound care.
3. Wear gown and mask during procedures.
4. Change invasive lines once a week.
5. Administer antibiotics as prescribed. - correct answer ✔✔1. Perform meticulous hand
hygiene.
The nurse is caring for a client with deep partial-thickness and full-thickness burns
to the chest area. Which assessment data would warrant notifying the health-care
provider?
1. The client is complaining of severe pain.
