When planning care for a male client with burns on the upper torso, which nursing diagnosis
should take the highest priority?
A. ineffective airway clearance related to edema of the respiratory passages
B. impaired physical mobility related to the disease process
C. disturbed sleep pattern related to facility environment
D. Risk for infection related to breaks in the skin correct answers ineffective airway clearance
In a female client with burns on the legs, which nursing intervention helps prevent contractures?
A. Applying knee splints
B. elevating the foot of the bed
C. hyperextending the client's palms
D. performing shoulder range of motion exercises correct answers applying knee splints
A female client is brought into the ED with second and third degree burns on the left arm, left
anterior leg, and anterior trunk. Using the rule of nines, what is the total body surface area that
has been burned?
A. 18%
B. 27%
C. 30%
D. 36% correct answers 36%
Which nursing intervention can help a client maintain healthy skin?
A. keep the client well hydrated
B. avoid bathing the client with mild soap
C. remove adhesive tape quickly from the skin
,D. recommend wearing right-fitting clothes in hot weather correct answers keep the client well
hydrated
A male client with psoriasis visits a dermatology clinic. when inspecting the affected areas, the
nurse expects to see which type of secondary lesion?
A. Scale
B. Crust
C. Ulcer
D. Scar correct answers scale
Nurse Bea plans to administer dexamethasone cream to a client who has dermatitis over the
anterior chest. How should the nurse apply this topical agent?
A. with a circular motion, to enhance absorption
B. with an upward motion, to increase blood supply to the affected area
C. in long, even, outward, and downward strokes in the direction of hair growth
D. in long, even, outward, and upward strokes in the direction opposite hair growth. correct
answers in long, even, outward, and downward strokes in the direction of hair growth
Nurse Mary is caring for a wheelchair-bound client. which piece of equipment impedes
circulation to the area it's mean to protect?
A. polyurethane foam mattress
B Ring or donut
C. gel flotation pad
D. water bed correct answers ring or donut
Nurse Harry documents the presence of a scab on a client's deep wound. The nurse identifies this
as which phase of wound healing?
A. inflammatory
B. migratory
,C. proliferative
D. maturation correct answers migratory
A female client with second and third degree burns on the arms receives autografts. two days
later, the nurse finds the client doing arm exercises. the nurse knows that the client should avoid
exercise because it may:
A. dislodge the autographs
B. increase edema in the arms
C. increase the amount of scarring
D. decrease circulation to the fingers correct answers dislodge the autographs
A male client is diagnosed with gonorrhea. When teaching the client about this disease, the nurse
should include which instruction?
A. avoid sexual intercourse until you've completed treatment, which takes 14-21 days
B. wash your hands thoroughly to avoid transferring the infection to your eyes
C.If you have intercourse before treatment ends, tell sexual partners of your status and have them
wash well after intercourse
D. if you don't get treatment, you may develop meningitis, and suffer widespread central nervous
system damage correct answers wash your hands thoroughly to avoid spreading the infection to
your eyes
A female client with genital herpes simplex is being treated in outpatient department. The nurse
teaches her about measures that may prevent herpes recurrences and emphasizes the need for
prompt treatment if complications arise. Genital herpes simplex increases the risk of:
A. cancer of the ovaries
B. cancer of the uterus
C. cancer of the cervix
D. cancer of the vagina correct answers cancer of the cervix
, Nurse Jody formulates a nursing diagnosis of impaired physical mobility for a client with third-
degree burns on the lower portions of both legs. To complete the nursing diagnosis statement, the
nurse should add which "related to" phrase?
A.related to fat emboli
B. related to infection
C. related to femoral artery occlusion
D. related to circumferential eschar correct answers related to circumferential eschar
The nurse is assessing for the presence of cyanosis in a male dark-skinned client. the nurse
understands that which body area would provide the best assessment?
A. lips
B. sacrum
C. earlobes
D. back of the hands correct answers lips
Which of the following individuals is least likely to be at risk of developing psoriasis?
A. a 32-year old African American
B. A woman experiencing menopause
C. A client with a family history of the disorder
D. an individual who has experienced a significant amount of emotional distress correct answers
a 32 year old African American
Which of the following clients would least likely be at risk of developing skin breakdown?
A. a client incontinent of urine feces
B. a client with nutritional deficiencies
C. a client with decreased sensory perception
D. a client who is unable to move about and is confined to bed correct answers A client with
decreased sensory perception