NURS4500 Final Exam (Skin) questions with
answers
The bclient bcomes binto bthe bemergency broom bin bsevere bpain band breports bthat ba bpot bof bboiling bhot
bwater baccidentally bspilled bon bhis blower blegs. bThe bassessment breveals bblistered, bmottled bred bskin,
band bboth bfeet bare bedematous. bWhich bdepth bof bburn bshould bthe bnurse bdocument?
1. bSuperficial bpartial bthickness.
2. bDeep bpartial bthickness.
3. bFull bthickness.
4. bFirst bdegree. b- bANSWER: b b➡ b2. bDeep bpartial bthickness.
The bclient bwith bfull-thickness bburns bto b40% bof bthe bbody, bincluding bboth blegs, bis bbeing btransferred
bfrom ba bcommunity bhospital bto ba bburn bcenter. bWhich bmeasure bshould bbe binstituted bbefore bthe
btransfer?
1. bA b22-gauge bintravenous bline bwith bnormal bsaline binfusing.
2. bWounds bcovered bwith bmoist bsterile bdressings.
3. bNo bintravenous bpain bmedication.
4. bAdequate bperipheral bcirculation bto bboth bfeet bensured. b- bANSWER: b b➡ b4. bAdequate bperipheral
bcirculation bto bboth bfeet bensured.
The bclient bhas bfull-thickness bburns bto b65% bof bthe bbody, bincluding bthe bchest barea. bAfter
bestablishing ba bpatent bairway, bwhich bcollaborative bintervention bis bpriority bfor bthe bclient?
1. bReplace bfluids band belectrolytes.
2. bPrevent bcontractures bof bextremities.
3. bMonitor burine boutput bhourly.
4. bPrepare bto bassist bwith ban bescharotomy. b- bANSWER: b b➡ b1. bReplace bfluids band belectrolytes.
,The bnurse bis bapplying bmafenide bacetate b(Sulfamylon), ba bsulfa bantibiotic bcream, bto ba
client's blower bextremity bburn. bWhich bassessment bdata bwould brequire bimmediate battention bby bthe
bnurse?
1. bThe bclient bcomplains bof bpain bwhen bthe bmedication bis badministered.
2. bThe bclient's bpotassium blevel bis b3.9 bmEq/L band bsodium blevel bis b137 bmEq/L.
3. bThe bclient's bABGs bare bpH b7.34, bPaO2 b98, bPaCO2 b38, band bHCO3 b20.
4. bThe bclient bis bable bto bperform bactive brange-of-motion bexercises. b- bANSWER: b b➡ b3. bThe bclient's
bABGs bare bpH b7.34, bPaO2 b98, bPaCO2 b38, band bHCO3 b20.
The bclient bis bscheduled bto bhave ba bxenograft bto ba bleft blower-leg bburn. bThe bclient basks bthe bnurse,
b"What bis ba bxenograft?" bWhich bstatement bby bthe bnurse bwould bbe bthe bbest bresponse?
1. b"The bdoctor bwill bgraft bskin bfrom byour bback bto byour bleg."
2. b"The bskin bfrom ba bdonor bwill bbe bused bto bcover byour bburn."
3. b"The bgraft bwill bcome bfrom ban banimal, bprobably ba bpig."
4. b"I bthink byou bshould bask byour bdoctor babout bthe bgraft." b- bANSWER: b b➡ b3. b"The bgraft bwill bcome
bfrom ban banimal, bprobably ba bpig."
The bintensive bcare bunit b(ICU) bburn bnurse bis bdeveloping ba bnursing bcare bplan bfor ba bclient bwith bsevere
bfull-thickness band bdeep bpartial-thickness bburns bover bhalf bthe bbody. bWhich bclient bproblem bhas
bpriority?
1. bHigh brisk bfor binfection.
2. bIneffective bcoping.
3. bImpaired bphysical bmobility.
4. bKnowledge bdeficit. b- bANSWER: b b➡ b1. bHigh brisk bfor binfection.
The bnurse bwrites bthe bnursing bdiagnosis b"impaired bskin bintegrity brelated bto bopen bburn bwounds."
bWhich bintervention bwould bbe bappropriate bfor bthis bnursing bdiagnosis?
1. bProvide banalgesia bbefore bpain bbecomes bsevere.
, 2. bClean bthe bclient's bwounds, bbody, band bhair bdaily.
3. bScreen bvisitors bfor brespiratory binfections.
4. bEncourage bvisitors bto bbring bplants band bflowers. b- bANSWER: b b➡ b2. bClean bthe bclient's bwounds,
bbody, band bhair bdaily.
Which bnursing binterventions bshould bbe bincluded bfor bthe bclient bwho bhas bfull-thickness band bdeep
bpartial-thickness bburns bto b50% bof bthe bbody? bSelect ball bthat bapply.
1. bPerform bmeticulous bhand bhygiene.
2. bUse bsterile bgloves bfor bwound bcare.
3. bWear bgown band bmask bduring bprocedures.
4. bChange binvasive blines bonce ba bweek.
5. bAdminister bantibiotics bas bprescribed. b- bANSWER: b b➡ b1. bPerform bmeticulous bhand bhygiene.
The bnurse bis bcaring bfor ba bclient bwith bdeep bpartial-thickness band bfull-thickness bburns
to bthe bchest barea. bWhich bassessment bdata bwould bwarrant bnotifying bthe bhealth-care
provider?
1. bThe bclient bis bcomplaining bof bsevere bpain.
2. bThe bclient's bpulse boximeter breading bis b95%.
3. bThe bclient bhas bT b100.4°F, bP b100, bR b24, band bBP b102/60.
4. bThe bclient's burinary boutput bis b50 bmL bin btwo b(2) bhours. b- bANSWER: b b➡ b4. bThe bclient's burinary
boutput bis b50 bmL bin btwo b(2) bhours.
The bclient bis badmitted bwith bfull-thickness band bpartial-thickness bburns bto bmore bthan
30% bof bthe bbody. bThe bnurse bis bconcerned bwith bthe bclient's bnutritional bstatus. bWhich
intervention bshould bthe bnurse bimplement?
1. bEncourage bthe bclient's bfamily bto bbring bfavorite bfoods.
2. bProvide ba blow-fat, blow-cholesterol bdiet bfor bthe bclient.
3. bMonitor bthe bclient's bweight bweekly bin bthe bsame bclothes.
answers
The bclient bcomes binto bthe bemergency broom bin bsevere bpain band breports bthat ba bpot bof bboiling bhot
bwater baccidentally bspilled bon bhis blower blegs. bThe bassessment breveals bblistered, bmottled bred bskin,
band bboth bfeet bare bedematous. bWhich bdepth bof bburn bshould bthe bnurse bdocument?
1. bSuperficial bpartial bthickness.
2. bDeep bpartial bthickness.
3. bFull bthickness.
4. bFirst bdegree. b- bANSWER: b b➡ b2. bDeep bpartial bthickness.
The bclient bwith bfull-thickness bburns bto b40% bof bthe bbody, bincluding bboth blegs, bis bbeing btransferred
bfrom ba bcommunity bhospital bto ba bburn bcenter. bWhich bmeasure bshould bbe binstituted bbefore bthe
btransfer?
1. bA b22-gauge bintravenous bline bwith bnormal bsaline binfusing.
2. bWounds bcovered bwith bmoist bsterile bdressings.
3. bNo bintravenous bpain bmedication.
4. bAdequate bperipheral bcirculation bto bboth bfeet bensured. b- bANSWER: b b➡ b4. bAdequate bperipheral
bcirculation bto bboth bfeet bensured.
The bclient bhas bfull-thickness bburns bto b65% bof bthe bbody, bincluding bthe bchest barea. bAfter
bestablishing ba bpatent bairway, bwhich bcollaborative bintervention bis bpriority bfor bthe bclient?
1. bReplace bfluids band belectrolytes.
2. bPrevent bcontractures bof bextremities.
3. bMonitor burine boutput bhourly.
4. bPrepare bto bassist bwith ban bescharotomy. b- bANSWER: b b➡ b1. bReplace bfluids band belectrolytes.
,The bnurse bis bapplying bmafenide bacetate b(Sulfamylon), ba bsulfa bantibiotic bcream, bto ba
client's blower bextremity bburn. bWhich bassessment bdata bwould brequire bimmediate battention bby bthe
bnurse?
1. bThe bclient bcomplains bof bpain bwhen bthe bmedication bis badministered.
2. bThe bclient's bpotassium blevel bis b3.9 bmEq/L band bsodium blevel bis b137 bmEq/L.
3. bThe bclient's bABGs bare bpH b7.34, bPaO2 b98, bPaCO2 b38, band bHCO3 b20.
4. bThe bclient bis bable bto bperform bactive brange-of-motion bexercises. b- bANSWER: b b➡ b3. bThe bclient's
bABGs bare bpH b7.34, bPaO2 b98, bPaCO2 b38, band bHCO3 b20.
The bclient bis bscheduled bto bhave ba bxenograft bto ba bleft blower-leg bburn. bThe bclient basks bthe bnurse,
b"What bis ba bxenograft?" bWhich bstatement bby bthe bnurse bwould bbe bthe bbest bresponse?
1. b"The bdoctor bwill bgraft bskin bfrom byour bback bto byour bleg."
2. b"The bskin bfrom ba bdonor bwill bbe bused bto bcover byour bburn."
3. b"The bgraft bwill bcome bfrom ban banimal, bprobably ba bpig."
4. b"I bthink byou bshould bask byour bdoctor babout bthe bgraft." b- bANSWER: b b➡ b3. b"The bgraft bwill bcome
bfrom ban banimal, bprobably ba bpig."
The bintensive bcare bunit b(ICU) bburn bnurse bis bdeveloping ba bnursing bcare bplan bfor ba bclient bwith bsevere
bfull-thickness band bdeep bpartial-thickness bburns bover bhalf bthe bbody. bWhich bclient bproblem bhas
bpriority?
1. bHigh brisk bfor binfection.
2. bIneffective bcoping.
3. bImpaired bphysical bmobility.
4. bKnowledge bdeficit. b- bANSWER: b b➡ b1. bHigh brisk bfor binfection.
The bnurse bwrites bthe bnursing bdiagnosis b"impaired bskin bintegrity brelated bto bopen bburn bwounds."
bWhich bintervention bwould bbe bappropriate bfor bthis bnursing bdiagnosis?
1. bProvide banalgesia bbefore bpain bbecomes bsevere.
, 2. bClean bthe bclient's bwounds, bbody, band bhair bdaily.
3. bScreen bvisitors bfor brespiratory binfections.
4. bEncourage bvisitors bto bbring bplants band bflowers. b- bANSWER: b b➡ b2. bClean bthe bclient's bwounds,
bbody, band bhair bdaily.
Which bnursing binterventions bshould bbe bincluded bfor bthe bclient bwho bhas bfull-thickness band bdeep
bpartial-thickness bburns bto b50% bof bthe bbody? bSelect ball bthat bapply.
1. bPerform bmeticulous bhand bhygiene.
2. bUse bsterile bgloves bfor bwound bcare.
3. bWear bgown band bmask bduring bprocedures.
4. bChange binvasive blines bonce ba bweek.
5. bAdminister bantibiotics bas bprescribed. b- bANSWER: b b➡ b1. bPerform bmeticulous bhand bhygiene.
The bnurse bis bcaring bfor ba bclient bwith bdeep bpartial-thickness band bfull-thickness bburns
to bthe bchest barea. bWhich bassessment bdata bwould bwarrant bnotifying bthe bhealth-care
provider?
1. bThe bclient bis bcomplaining bof bsevere bpain.
2. bThe bclient's bpulse boximeter breading bis b95%.
3. bThe bclient bhas bT b100.4°F, bP b100, bR b24, band bBP b102/60.
4. bThe bclient's burinary boutput bis b50 bmL bin btwo b(2) bhours. b- bANSWER: b b➡ b4. bThe bclient's burinary
boutput bis b50 bmL bin btwo b(2) bhours.
The bclient bis badmitted bwith bfull-thickness band bpartial-thickness bburns bto bmore bthan
30% bof bthe bbody. bThe bnurse bis bconcerned bwith bthe bclient's bnutritional bstatus. bWhich
intervention bshould bthe bnurse bimplement?
1. bEncourage bthe bclient's bfamily bto bbring bfavorite bfoods.
2. bProvide ba blow-fat, blow-cholesterol bdiet bfor bthe bclient.
3. bMonitor bthe bclient's bweight bweekly bin bthe bsame bclothes.
