Exam 3 Test Bank Burns & Skin Exam
Questions and Answers
nurse plans care for a client who has a wound that is not healing. Which focused
assessments should the
nurse complete to develop the clients plan of care? (Select all that apply.)
a. Height
b. Allergies
c. Alcohol use
d. Prealbumin laboratory results
e. Liver enzyme laboratory results - Answer-A,C,D
A nurse teaches a client to perform total skin self-examinations on a monthly basis.
Which statements should
the nurse include in this clients teaching? (Select all that apply.)
a. Look for asymmetry of shape and irregular borders.
b. Assess for color variation within each lesion.
c. Examine the distribution of lesions over a section of the body.
d. Monitor for edema or swelling of tissues.
e. Focus your assessment on skin areas that itch. - Answer-A,B
A nurse teaches a client who has very dry skin. Which statement should the nurse
include in this clients
education?
a. Use lots of moisturizer several times a day to minimize dryness.
b. Take a cold shower instead of soaking in the bathtub.
c. Use antimicrobial soap to avoid infection of cracked skin.
d. After you bathe, put lotion on before your skin is totally dry. - Answer-D
A nurse assesses clients on a medical-surgical unit. Which client is at greatest risk
for pressure ulcer
development?
a. A 44-year-old prescribed IV antibiotics for pneumonia
b. A 26-year-old who is bedridden with a fractured leg
c. A 65-year-old with hemi-paralysis and incontinence
d. A 78-year-old requiring assistance to ambulate with a walker - Answer-C
When transferring a client into a chair, a nurse notices that the pressure-relieving
mattress overlay has deep
imprints of the clients buttocks, heels, and scapulae. Which action should the nurse
take next?
a. Turn the mattress overlay to the opposite side.
b. Do nothing because this is an expected occurrence.
c. Apply a different pressure-relieving device.
d. Reinforce the overlay with extra cushions. - Answer-C
A nurse cares for a client who has a deep wound that is being treated with a wet-to-
damp dressing. Which
,intervention should the nurse include in this clients plan of care?
a. Change the dressing every 6 hours.
b. Assess the wound bed once a day.
c. Change the dressing when it is saturated.
d. Contact the provider when the dressing leaks. - Answer-A
A nurse is caring for a client who has a pressure ulcer on the right ankle. Which
action should the nurse take
first?
a. Draw blood for albumin, prealbumin, and total protein.
b. Prepare for and assist with obtaining a wound culture.
c. Place the client in bed and instruct the client to elevate the foot.
d. Assess the right leg for pulses, skin color, and temperature. - Answer-D
After educating a caregiver of a home care client, a nurse assesses the caregivers
understanding. Which
statement indicates that the caregiver needs additional education?
a. I can help him shift his position every hour when he sits in the chair.
b. If his tailbone is red and tender in the morning, I will massage it with baby oil.
c. Applying lotion to his arms and legs every evening will decrease dryness.
d. Drinking a nutritional supplement between meals will help maintain his weight. -
Answer-B
After teaching a client who is at risk for the formation of pressure ulcers, a nurse
assesses the clients
understanding. Which dietary choice by the client indicates a good understanding of
the teaching?
a. Low-fat diet with whole grains and cereals and vitamin supplements
b. High-protein diet with vitamins and mineral supplements
c. Vegetarian diet with nutritional supplements and fish oil capsules
d. Low-fat, low-cholesterol, high-fiber, low-carbohydrate diet - Answer-B
A nurse assesses clients on a medical-surgical unit. Which client should the nurse
evaluate for a wound
infection?
a. Client with blood cultures pending
b. Client who has thin, serous wound drainage
c. Client with a white blood cell count of 23,000/mm3
d. Client whose wound has decreased in size - Answer-C
A nurse who manages client placements prepares to place four clients on a medical-
surgical unit. Which
client should be placed in isolation awaiting possible diagnosis of infection with
methicillin-resistant
Staphylococcus aureus(MRSA)?
a. Client admitted from a nursing home with furuncles and folliculitis
b. Client with a leg cut and other trauma from a motorcycle crash
c. Client with a rash noticed after participating in sporting events
d. Client transferred from intensive care with an elevated white blood cell count -
Answer-A
, After teaching a client how to care for a furuncle in the axilla, a nurse assesses the
clients understanding.
Which statement indicates the client correctly understands the teaching?
a. Ill apply cortisone cream to reduce the inflammation.
b. Ill apply a clean dressing after squeezing out the pus.
c. Ill keep my arm down at my side to prevent spread.
d. Ill cleanse the area prior to applying antibiotic cream. - Answer-D
A nurse assesses an older client who is scratching and rubbing white ridges on the
skin between the fingers and on the wrists. Which action should the nurse take?
a. Place the client in a single room.
b. Administer an antihistamine.
c. Assess the clients airway.
d. Apply gloves to minimize friction. - Answer-A
A nurse assesses a client who has a chronic wound. The client states, I do not clean
the wound and change
the dressing every day because it costs too much for supplies. How should the nurse
respond?
a. You can use tap water instead of sterile saline to clean your wound.
b. If you dont clean the wound properly, you could end up in the hospital.
c. Sterile procedure is necessary to keep this wound from getting infected.
d. Good hand hygiene is the only thing that really matters with wound care. -
Answer-A
After teaching a client who has psoriasis, a nurse assesses the clients
understanding. Which statement
indicates the client needs additional teaching?
a. At the next family reunion, Im going to ask my relatives if they have psoriasis.
b. I have to make sure I keep my lesions covered, so I do not spread this to others.
c. I expect that these patches will get smaller when I lie out in the sun.
d. I should continue to use the cortisone ointment as the patches shrink and dry out.
- Answer-B
A nurse performs a skin screening for a client who has numerous skin lesions. Which
lesion does the nurse
evaluate first?
a. Beige freckles on the backs of both hands
b. Irregular blue mole with white specks on the lower leg
c. Large cluster of pustules in the right axilla
d. Thick, reddened papules covered by white scales - Answer-B
A nurse cares for a client who is prescribed vancomycin (Vancocin) 500 mg IV every
6 hours for a
methicillin-resistant Staphylococcus aureus (MRSA) infection. Which action should
the nurse take?
a. Administer it over 30 minutes using an IV pump.
b. Give the client diphenhydramine (Benadryl) before the drug.
c. Assess the IV site at least every 2 hours for thrombophlebitis.
Questions and Answers
nurse plans care for a client who has a wound that is not healing. Which focused
assessments should the
nurse complete to develop the clients plan of care? (Select all that apply.)
a. Height
b. Allergies
c. Alcohol use
d. Prealbumin laboratory results
e. Liver enzyme laboratory results - Answer-A,C,D
A nurse teaches a client to perform total skin self-examinations on a monthly basis.
Which statements should
the nurse include in this clients teaching? (Select all that apply.)
a. Look for asymmetry of shape and irregular borders.
b. Assess for color variation within each lesion.
c. Examine the distribution of lesions over a section of the body.
d. Monitor for edema or swelling of tissues.
e. Focus your assessment on skin areas that itch. - Answer-A,B
A nurse teaches a client who has very dry skin. Which statement should the nurse
include in this clients
education?
a. Use lots of moisturizer several times a day to minimize dryness.
b. Take a cold shower instead of soaking in the bathtub.
c. Use antimicrobial soap to avoid infection of cracked skin.
d. After you bathe, put lotion on before your skin is totally dry. - Answer-D
A nurse assesses clients on a medical-surgical unit. Which client is at greatest risk
for pressure ulcer
development?
a. A 44-year-old prescribed IV antibiotics for pneumonia
b. A 26-year-old who is bedridden with a fractured leg
c. A 65-year-old with hemi-paralysis and incontinence
d. A 78-year-old requiring assistance to ambulate with a walker - Answer-C
When transferring a client into a chair, a nurse notices that the pressure-relieving
mattress overlay has deep
imprints of the clients buttocks, heels, and scapulae. Which action should the nurse
take next?
a. Turn the mattress overlay to the opposite side.
b. Do nothing because this is an expected occurrence.
c. Apply a different pressure-relieving device.
d. Reinforce the overlay with extra cushions. - Answer-C
A nurse cares for a client who has a deep wound that is being treated with a wet-to-
damp dressing. Which
,intervention should the nurse include in this clients plan of care?
a. Change the dressing every 6 hours.
b. Assess the wound bed once a day.
c. Change the dressing when it is saturated.
d. Contact the provider when the dressing leaks. - Answer-A
A nurse is caring for a client who has a pressure ulcer on the right ankle. Which
action should the nurse take
first?
a. Draw blood for albumin, prealbumin, and total protein.
b. Prepare for and assist with obtaining a wound culture.
c. Place the client in bed and instruct the client to elevate the foot.
d. Assess the right leg for pulses, skin color, and temperature. - Answer-D
After educating a caregiver of a home care client, a nurse assesses the caregivers
understanding. Which
statement indicates that the caregiver needs additional education?
a. I can help him shift his position every hour when he sits in the chair.
b. If his tailbone is red and tender in the morning, I will massage it with baby oil.
c. Applying lotion to his arms and legs every evening will decrease dryness.
d. Drinking a nutritional supplement between meals will help maintain his weight. -
Answer-B
After teaching a client who is at risk for the formation of pressure ulcers, a nurse
assesses the clients
understanding. Which dietary choice by the client indicates a good understanding of
the teaching?
a. Low-fat diet with whole grains and cereals and vitamin supplements
b. High-protein diet with vitamins and mineral supplements
c. Vegetarian diet with nutritional supplements and fish oil capsules
d. Low-fat, low-cholesterol, high-fiber, low-carbohydrate diet - Answer-B
A nurse assesses clients on a medical-surgical unit. Which client should the nurse
evaluate for a wound
infection?
a. Client with blood cultures pending
b. Client who has thin, serous wound drainage
c. Client with a white blood cell count of 23,000/mm3
d. Client whose wound has decreased in size - Answer-C
A nurse who manages client placements prepares to place four clients on a medical-
surgical unit. Which
client should be placed in isolation awaiting possible diagnosis of infection with
methicillin-resistant
Staphylococcus aureus(MRSA)?
a. Client admitted from a nursing home with furuncles and folliculitis
b. Client with a leg cut and other trauma from a motorcycle crash
c. Client with a rash noticed after participating in sporting events
d. Client transferred from intensive care with an elevated white blood cell count -
Answer-A
, After teaching a client how to care for a furuncle in the axilla, a nurse assesses the
clients understanding.
Which statement indicates the client correctly understands the teaching?
a. Ill apply cortisone cream to reduce the inflammation.
b. Ill apply a clean dressing after squeezing out the pus.
c. Ill keep my arm down at my side to prevent spread.
d. Ill cleanse the area prior to applying antibiotic cream. - Answer-D
A nurse assesses an older client who is scratching and rubbing white ridges on the
skin between the fingers and on the wrists. Which action should the nurse take?
a. Place the client in a single room.
b. Administer an antihistamine.
c. Assess the clients airway.
d. Apply gloves to minimize friction. - Answer-A
A nurse assesses a client who has a chronic wound. The client states, I do not clean
the wound and change
the dressing every day because it costs too much for supplies. How should the nurse
respond?
a. You can use tap water instead of sterile saline to clean your wound.
b. If you dont clean the wound properly, you could end up in the hospital.
c. Sterile procedure is necessary to keep this wound from getting infected.
d. Good hand hygiene is the only thing that really matters with wound care. -
Answer-A
After teaching a client who has psoriasis, a nurse assesses the clients
understanding. Which statement
indicates the client needs additional teaching?
a. At the next family reunion, Im going to ask my relatives if they have psoriasis.
b. I have to make sure I keep my lesions covered, so I do not spread this to others.
c. I expect that these patches will get smaller when I lie out in the sun.
d. I should continue to use the cortisone ointment as the patches shrink and dry out.
- Answer-B
A nurse performs a skin screening for a client who has numerous skin lesions. Which
lesion does the nurse
evaluate first?
a. Beige freckles on the backs of both hands
b. Irregular blue mole with white specks on the lower leg
c. Large cluster of pustules in the right axilla
d. Thick, reddened papules covered by white scales - Answer-B
A nurse cares for a client who is prescribed vancomycin (Vancocin) 500 mg IV every
6 hours for a
methicillin-resistant Staphylococcus aureus (MRSA) infection. Which action should
the nurse take?
a. Administer it over 30 minutes using an IV pump.
b. Give the client diphenhydramine (Benadryl) before the drug.
c. Assess the IV site at least every 2 hours for thrombophlebitis.
