NCLEX 10000 Integumentary Disorders (NCLEX) Questions & Answers

NCLEX 10000 Integumentary Disorders (NCLEX) Questions & Answers-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 - 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. - 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 - 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. e) The child must be monitored for signs of fluid shift - • This is a severe burn and nerve endings have been destroyed. • The child must be monitored for signs of fluid shift. • Rehabilitation and skin grafting will be necessary. Correct Explanation: This is an example of a third-degree burn, which is very serious. This child must be carefully monitored for complications. The fact that there is no pain is due to the destruction of the nerve endings. Fluid shift can occur and result in shock. A burn of this degree will also require a long rehabilitation with skin grafting. A client is recovering from an infected abdominal wound. Which foods should the nurse encourage the client to eat to support wound healing and recovery from the infection? a) cheeseburger and french fries b) cheese omelet and bacon c) gelatin salad and tea d) chicken and orange slices - chicken and orange slices Correct