Summary - NCLEX 10000 Integumentary
Disorders (NCLEX)(2025) Questions and
Correct Answers/ Latest Update /
Already Graded
When assessing a client with partial-thickness burns over 60% of the
body, which finding should the nurse report immediately?
a) Complaints of intense thirst
b) Moderate to severe pain
c) Hoarseness of the voice
d) Urine output of 70 ml the first hour
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Ans: Hoarseness of the voice
Correct
Explanation:
Hoarseness is indicative of injury to the respiratory system and could
indicate the need for immediate intubation
What is the primary goal of nursing care during the emergent phase
after a burn injury?
a) Promote wound healing.
b) Replace lost fluids.
c) Control pain.
d) Prevent infection.
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Ans: Replace lost fluids.
Correct
Explanation:
During the emergent phase of burn care, one of the most significant
problems is hypovolemic shock. The development of hypovolemic shock
can lead to impaired blood flow through the heart and kidneys, resulting
in decreased cardiac output and renal ischemia. Efforts are directed
toward replacing lost fluids and preventing hypovolemic shock.
The nurse is evaluating the client's risk for having a pressure sore.
Which is the best indicator of risk for the client's developing a
pressure sore?
a) nutritional status
b) orientation status
c) circulatory status
d) mobility status
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Ans: mobility status
Correct
Explanation:
The client's mobility status is the best indicator of risk for development of a
pressure sore.
A child is brought to the emergency department with a full-thickness
burn involving the epidermis, dermis, and underlying subcutaneous
tissue, but does not report pain at this time. Which of the following
statements by the nurse are correct about this type of burn? Select
all that apply.
a) This is a severe burn and nerve endings have been destroyed.
b) Rehabilitation and skin grafting will be necessary.
c) Pain medication has been administered orally and was effective.
d) This is a superficial burn, so no pain is present.