NCLEX 10000 INTEGUMENTARY
A client is receiving fluid replacement with lactated Ringer's after 40% of the body was
burned 10 hours ago. The assessment reveals temperature 97.1° F (36.2° C), heart rate
122 bpm, blood pressure 84/42 mm Hg, central venous pressure (CVP) 2 mm Hg, and
urine output 25 mL for the last 2 hours. The IV rate is currently at 375 mL/h. Using the
SBAR (Situation-Background-Assessment-Recommendation) technique for
communication, the nurse calls the health care provider (HCP) with a recommendation
for: - IV rate increase
Which factor is most important for the nurse to consider when determining the angle at
which to insert the needle for a subcutaneous injection? - amount of subcutaneous
tissue
While caring for the client with a burn injury who is experiencing hypersecretion of
gastric acid, the nurse should observe the client for: - gastrointestinal ulceration.
A nurse is preparing a discharge teaching plan for a client with atopic dermatitis. Which
instruction should the nurse include in her teaching plan? - Use a topical skin
moisturizer daily.
A client with deep partial-thickness and full-thickness burns on the arms receives
autografts. Two days later, the nurse finds the client doing arm exercises. The nurse
provides additional client teaching because these exercises may: - dislodge the
autografts.
A client who was bitten by a wild animal is admitted to an acute care facility for
treatment of rabies. Which type of isolation does this client require? - Contact
Which instruction is the most important to give a client who has recently had a skin
graft? - Protect the graft from direct sunlight.
A client received burns to his entire back and left arm. Using the Rule of Nines, the
nurse can calculate that he has sustained burns on what percentage of his body? - 27%
A client with right sided hemiparesis has limited mobility. Which action should the nurse
include in the plan of care to help maintain skin integrity? - Turn him regularly.
When assessing a client with partial-thickness burns over 60% of the body, which
finding should the nurse report immediately? - Hoarseness of the voice
Which disciplines should be consulted when caring for a client with a stage III heel
ulcer? - Nutrition support and orthotics
,A night-shift nurse receives a call from the emergency department about a client with
herpes zoster who is going to be admitted to the floor. Based on this diagnosis, where
should the nurse assign the client? - Private room
A nurse is caring for a client with severe burns and receiving fluid resuscitation. Which
finding indicates that the client is responding to the fluid resuscitation? - urine output of
30 mL/h
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. - 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.
The nurse is caring for an immune compromised client with a fungal infection of the
scalp. What recommendation should the nurse make to prevent future problems? -
Avoid sharing combs and brushes.
Which statement would be appropriate for a nurse documenting a stage 1 pressure
ulcer found on a client who is immobilized? - The client's skin is intact with non-
blanchable redness of a localized area over a bony prominence.
The nurse is applying a hand mitt restraint for a client with pruritus (see figure). The
nurse should first: - verify the prescription to use the restraint.
A client reports a firm, red nodule with a scaly crust on his back. Which of the following
is the best nursing intervention? - Notify the healthcare provider.
A teenager asks advice from a nurse about getting a tattoo. When the nurse is providing
education, which statement about tattoos is a common misconception? - Tattoos are
easily removed with laser surgery.
The nurse is discharging an older adult to home after hospitalization for cellulitis of the
right foot. The client originally scraped the foot on a rock while walking barefoot outside;
the scrape became infected and eventually required hospitalization for wound care and
several days of IV antibiotics. After reviewing discharge instructions, what statement by
the client indicates the need for further teaching by the nurse? - "I will take the
antibiotics until the redness goes away and my foot feels better."
"I will take the antibiotics until the redness goes away and my foot feels better." -
Replace lost fluids.
The nurse is assessing a client with a burn injury using the "rule of nines" to determine:
- amount of body surface area burned.
, The client with a major burn injury receives total parenteral nutrition (TPN). The
expected outcome is to: - ensure adequate caloric and protein intake.
A nurse is assessing a client admitted with deep partial-thickness and full-thickness
burns on the face, arms, and chest. Which finding indicates a potential problem? - Urine
output of 20 ml/hour
A client visits the physician's office for treatment of a skin disorder. As a primary
treatment, the nurse expects the physician to order: - a topical agent.
A nurse is developing a care plan for a client recovering from a serious thermal burn.
What does the nurse determine is the priority goal of therapy? - Maintaining the client's
fluid and electrolyte balance
An occupational nurse is called to treat an employee who experienced a finger injury on
a piece of equipment. When the nurse arrives, it is discovered that the finger tip was cut
off at the first digit and is bleeding profusely. What should be the nurse's first action? -
Apply direct pressure to the finger with a clean, dry cloth.
When planning care for a client with burns on the upper torso, which nursing diagnosis
should take the highest priority? - Ineffective airway clearance related to edema of the
respiratory passages
A nurse is caring for a client with a postoperative wound evisceration. Which action
should the nurse perform first? - Cover the protruding internal organs with sterile gauze,
moistened with sterile saline solution.
A nurse is evaluating a stage II pressure ulcer on a client. Which wound assessment
findings should prompt the nurse to request a referral from the wound care nurse? - A
wound measuring 2 cm × 2 cm × 0.5 cm with tan leathery appearan
After sustaining a stroke, a client is transferred to the rehabilitation unit. The medical-
surgical nurse reviews the client's residual neurological deficits with the rehabilitation
nurse. Which neurological deficit places the client at the greatest risk for skin
breakdown? - Incontinence and right-sided hemiparesis
A nurse is preparing a care plan for a client burned over 36% of his body 2 days
previously. Which clinical manifestation indicates that the client has progressed into the
intermediate phase of burn care? - The client's complete blood count readings reflect a
reduced hematocrit.
A nurse is assessing an immobile client and notes an area of sacral skin is reddened,
but not broken. The reddened area continues to blanch and refill with fingertip pressure.
The most appropriate nursing action at this time is to: - reposition the client off the
reddened skin and reassess in a few hours.
A client is receiving fluid replacement with lactated Ringer's after 40% of the body was
burned 10 hours ago. The assessment reveals temperature 97.1° F (36.2° C), heart rate
122 bpm, blood pressure 84/42 mm Hg, central venous pressure (CVP) 2 mm Hg, and
urine output 25 mL for the last 2 hours. The IV rate is currently at 375 mL/h. Using the
SBAR (Situation-Background-Assessment-Recommendation) technique for
communication, the nurse calls the health care provider (HCP) with a recommendation
for: - IV rate increase
Which factor is most important for the nurse to consider when determining the angle at
which to insert the needle for a subcutaneous injection? - amount of subcutaneous
tissue
While caring for the client with a burn injury who is experiencing hypersecretion of
gastric acid, the nurse should observe the client for: - gastrointestinal ulceration.
A nurse is preparing a discharge teaching plan for a client with atopic dermatitis. Which
instruction should the nurse include in her teaching plan? - Use a topical skin
moisturizer daily.
A client with deep partial-thickness and full-thickness burns on the arms receives
autografts. Two days later, the nurse finds the client doing arm exercises. The nurse
provides additional client teaching because these exercises may: - dislodge the
autografts.
A client who was bitten by a wild animal is admitted to an acute care facility for
treatment of rabies. Which type of isolation does this client require? - Contact
Which instruction is the most important to give a client who has recently had a skin
graft? - Protect the graft from direct sunlight.
A client received burns to his entire back and left arm. Using the Rule of Nines, the
nurse can calculate that he has sustained burns on what percentage of his body? - 27%
A client with right sided hemiparesis has limited mobility. Which action should the nurse
include in the plan of care to help maintain skin integrity? - Turn him regularly.
When assessing a client with partial-thickness burns over 60% of the body, which
finding should the nurse report immediately? - Hoarseness of the voice
Which disciplines should be consulted when caring for a client with a stage III heel
ulcer? - Nutrition support and orthotics
,A night-shift nurse receives a call from the emergency department about a client with
herpes zoster who is going to be admitted to the floor. Based on this diagnosis, where
should the nurse assign the client? - Private room
A nurse is caring for a client with severe burns and receiving fluid resuscitation. Which
finding indicates that the client is responding to the fluid resuscitation? - urine output of
30 mL/h
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. - 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.
The nurse is caring for an immune compromised client with a fungal infection of the
scalp. What recommendation should the nurse make to prevent future problems? -
Avoid sharing combs and brushes.
Which statement would be appropriate for a nurse documenting a stage 1 pressure
ulcer found on a client who is immobilized? - The client's skin is intact with non-
blanchable redness of a localized area over a bony prominence.
The nurse is applying a hand mitt restraint for a client with pruritus (see figure). The
nurse should first: - verify the prescription to use the restraint.
A client reports a firm, red nodule with a scaly crust on his back. Which of the following
is the best nursing intervention? - Notify the healthcare provider.
A teenager asks advice from a nurse about getting a tattoo. When the nurse is providing
education, which statement about tattoos is a common misconception? - Tattoos are
easily removed with laser surgery.
The nurse is discharging an older adult to home after hospitalization for cellulitis of the
right foot. The client originally scraped the foot on a rock while walking barefoot outside;
the scrape became infected and eventually required hospitalization for wound care and
several days of IV antibiotics. After reviewing discharge instructions, what statement by
the client indicates the need for further teaching by the nurse? - "I will take the
antibiotics until the redness goes away and my foot feels better."
"I will take the antibiotics until the redness goes away and my foot feels better." -
Replace lost fluids.
The nurse is assessing a client with a burn injury using the "rule of nines" to determine:
- amount of body surface area burned.
, The client with a major burn injury receives total parenteral nutrition (TPN). The
expected outcome is to: - ensure adequate caloric and protein intake.
A nurse is assessing a client admitted with deep partial-thickness and full-thickness
burns on the face, arms, and chest. Which finding indicates a potential problem? - Urine
output of 20 ml/hour
A client visits the physician's office for treatment of a skin disorder. As a primary
treatment, the nurse expects the physician to order: - a topical agent.
A nurse is developing a care plan for a client recovering from a serious thermal burn.
What does the nurse determine is the priority goal of therapy? - Maintaining the client's
fluid and electrolyte balance
An occupational nurse is called to treat an employee who experienced a finger injury on
a piece of equipment. When the nurse arrives, it is discovered that the finger tip was cut
off at the first digit and is bleeding profusely. What should be the nurse's first action? -
Apply direct pressure to the finger with a clean, dry cloth.
When planning care for a client with burns on the upper torso, which nursing diagnosis
should take the highest priority? - Ineffective airway clearance related to edema of the
respiratory passages
A nurse is caring for a client with a postoperative wound evisceration. Which action
should the nurse perform first? - Cover the protruding internal organs with sterile gauze,
moistened with sterile saline solution.
A nurse is evaluating a stage II pressure ulcer on a client. Which wound assessment
findings should prompt the nurse to request a referral from the wound care nurse? - A
wound measuring 2 cm × 2 cm × 0.5 cm with tan leathery appearan
After sustaining a stroke, a client is transferred to the rehabilitation unit. The medical-
surgical nurse reviews the client's residual neurological deficits with the rehabilitation
nurse. Which neurological deficit places the client at the greatest risk for skin
breakdown? - Incontinence and right-sided hemiparesis
A nurse is preparing a care plan for a client burned over 36% of his body 2 days
previously. Which clinical manifestation indicates that the client has progressed into the
intermediate phase of burn care? - The client's complete blood count readings reflect a
reduced hematocrit.
A nurse is assessing an immobile client and notes an area of sacral skin is reddened,
but not broken. The reddened area continues to blanch and refill with fingertip pressure.
The most appropriate nursing action at this time is to: - reposition the client off the
reddened skin and reassess in a few hours.
