NURS4500 Final Exam Skin questions with answers
The client comes into the emergency room in severe pain and reports that a pot of boiling hot water
accidentally spilled on his lower legs. The assessment reveals blistered, mottled red skin, and both feet
are edematous. Which depth of burn should the nurse document?
1. Superficial partial thickness.
2. Deep partial thickness.
3. Full thickness.
4. First degree. -Correct Answer-2. Deep partial thickness.
The client with full-thickness burns to 40% of the body, including both legs, is being transferred from a
community hospital to a burn center. Which measure should be instituted before the transfer?
1. A 22-gauge intravenous line with normal saline infusing.
2. Wounds covered with moist sterile dressings.
3. No intravenous pain medication.
4. Adequate peripheral circulation to both feet ensured. -Correct Answer-4. Adequate peripheral
circulation to both feet ensured.
The client has full-thickness burns to 65% of the body, including the chest area. After establishing a
patent airway, which collaborative intervention is priority for the client?
1. Replace fluids and electrolytes.
2. Prevent contractures of extremities.
3. Monitor urine output hourly.
4. Prepare to assist with an escharotomy. -Correct Answer-1. Replace fluids and electrolytes.
The nurse is applying mafenide acetate (Sulfamylon), a sulfa antibiotic cream, to a
client's lower extremity burn. Which assessment data would require immediate attention by the nurse?
1. The client complains of pain when the medication is administered.
2. The client's potassium level is 3.9 mEq/L and sodium level is 137 mEq/L.
3. The client's ABGs are pH 7.34, PaO2 98, PaCO2 38, and HCO3 20.
,4. The client is able to perform active range-of-motion exercises. -Correct Answer-3. The client's ABGs
are pH 7.34, PaO2 98, PaCO2 38, and HCO3 20.
The client is scheduled to have a xenograft to a left lower-leg burn. The client asks the nurse, "What is a
xenograft?" Which statement by the nurse would be the best response?
1. "The doctor will graft skin from your back to your leg."
2. "The skin from a donor will be used to cover your burn."
3. "The graft will come from an animal, probably a pig."
4. "I think you should ask your doctor about the graft." -Correct Answer-3. "The graft will come from an
animal, probably a pig."
The intensive care unit (ICU) burn nurse is developing a nursing care plan for a client with severe full-
thickness and deep partial-thickness burns over half the body. Which client problem has priority?
1. High risk for infection.
2. Ineffective coping.
3. Impaired physical mobility.
4. Knowledge deficit. -Correct Answer-1. High risk for infection.
The nurse writes the nursing diagnosis "impaired skin integrity related to open burn wounds." Which
intervention would be appropriate for this nursing diagnosis?
1. Provide analgesia before pain becomes severe.
2. Clean the client's wounds, body, and hair daily.
3. Screen visitors for respiratory infections.
4. Encourage visitors to bring plants and flowers. -Correct Answer-2. Clean the client's wounds, body, and
hair daily.
Which nursing interventions should be included for the client who has full-thickness and deep partial-
thickness burns to 50% of the body? Select all that apply.
1. Perform meticulous hand hygiene.
2. Use sterile gloves for wound care.
3. Wear gown and mask during procedures.
, 4. Change invasive lines once a week.
5. Administer antibiotics as prescribed. -Correct Answer-1. Perform meticulous hand hygiene.
The nurse is caring for a client with deep partial-thickness and full-thickness burns
to the chest area. Which assessment data would warrant notifying the health-care
provider?
1. The client is complaining of severe pain.
2. The client's pulse oximeter reading is 95%.
3. The client has T 100.4°F, P 100, R 24, and BP 102/60.
4. The client's urinary output is 50 mL in two (2) hours. -Correct Answer-4. The client's urinary output is
50 mL in two (2) hours.
The client is admitted with full-thickness and partial-thickness burns to more than
30% of the body. The nurse is concerned with the client's nutritional status. Which
intervention should the nurse implement?
1. Encourage the client's family to bring favorite foods.
2. Provide a low-fat, low-cholesterol diet for the client.
3. Monitor the client's weight weekly in the same clothes.
4. Make a referral to the hospital social worker. -Correct Answer-1. Encourage the client's family to bring
favorite foods.
The client sustained a hot grease burn to the right hand and calls the emergency
room for advice. Which information should the nurse provide to the client?
1. Apply an ice pack to the right hand.
2. Place the hand in cool water.
3. Be sure to rupture any blister formation.
4. Go immediately to the doctor's office. -Correct Answer-2. Place the hand in cool water.
The client is being discharged after being in the burn unit for six (6) weeks. Which
strategies should the nurse identify to promote the client's mental health?
The client comes into the emergency room in severe pain and reports that a pot of boiling hot water
accidentally spilled on his lower legs. The assessment reveals blistered, mottled red skin, and both feet
are edematous. Which depth of burn should the nurse document?
1. Superficial partial thickness.
2. Deep partial thickness.
3. Full thickness.
4. First degree. -Correct Answer-2. Deep partial thickness.
The client with full-thickness burns to 40% of the body, including both legs, is being transferred from a
community hospital to a burn center. Which measure should be instituted before the transfer?
1. A 22-gauge intravenous line with normal saline infusing.
2. Wounds covered with moist sterile dressings.
3. No intravenous pain medication.
4. Adequate peripheral circulation to both feet ensured. -Correct Answer-4. Adequate peripheral
circulation to both feet ensured.
The client has full-thickness burns to 65% of the body, including the chest area. After establishing a
patent airway, which collaborative intervention is priority for the client?
1. Replace fluids and electrolytes.
2. Prevent contractures of extremities.
3. Monitor urine output hourly.
4. Prepare to assist with an escharotomy. -Correct Answer-1. Replace fluids and electrolytes.
The nurse is applying mafenide acetate (Sulfamylon), a sulfa antibiotic cream, to a
client's lower extremity burn. Which assessment data would require immediate attention by the nurse?
1. The client complains of pain when the medication is administered.
2. The client's potassium level is 3.9 mEq/L and sodium level is 137 mEq/L.
3. The client's ABGs are pH 7.34, PaO2 98, PaCO2 38, and HCO3 20.
,4. The client is able to perform active range-of-motion exercises. -Correct Answer-3. The client's ABGs
are pH 7.34, PaO2 98, PaCO2 38, and HCO3 20.
The client is scheduled to have a xenograft to a left lower-leg burn. The client asks the nurse, "What is a
xenograft?" Which statement by the nurse would be the best response?
1. "The doctor will graft skin from your back to your leg."
2. "The skin from a donor will be used to cover your burn."
3. "The graft will come from an animal, probably a pig."
4. "I think you should ask your doctor about the graft." -Correct Answer-3. "The graft will come from an
animal, probably a pig."
The intensive care unit (ICU) burn nurse is developing a nursing care plan for a client with severe full-
thickness and deep partial-thickness burns over half the body. Which client problem has priority?
1. High risk for infection.
2. Ineffective coping.
3. Impaired physical mobility.
4. Knowledge deficit. -Correct Answer-1. High risk for infection.
The nurse writes the nursing diagnosis "impaired skin integrity related to open burn wounds." Which
intervention would be appropriate for this nursing diagnosis?
1. Provide analgesia before pain becomes severe.
2. Clean the client's wounds, body, and hair daily.
3. Screen visitors for respiratory infections.
4. Encourage visitors to bring plants and flowers. -Correct Answer-2. Clean the client's wounds, body, and
hair daily.
Which nursing interventions should be included for the client who has full-thickness and deep partial-
thickness burns to 50% of the body? Select all that apply.
1. Perform meticulous hand hygiene.
2. Use sterile gloves for wound care.
3. Wear gown and mask during procedures.
, 4. Change invasive lines once a week.
5. Administer antibiotics as prescribed. -Correct Answer-1. Perform meticulous hand hygiene.
The nurse is caring for a client with deep partial-thickness and full-thickness burns
to the chest area. Which assessment data would warrant notifying the health-care
provider?
1. The client is complaining of severe pain.
2. The client's pulse oximeter reading is 95%.
3. The client has T 100.4°F, P 100, R 24, and BP 102/60.
4. The client's urinary output is 50 mL in two (2) hours. -Correct Answer-4. The client's urinary output is
50 mL in two (2) hours.
The client is admitted with full-thickness and partial-thickness burns to more than
30% of the body. The nurse is concerned with the client's nutritional status. Which
intervention should the nurse implement?
1. Encourage the client's family to bring favorite foods.
2. Provide a low-fat, low-cholesterol diet for the client.
3. Monitor the client's weight weekly in the same clothes.
4. Make a referral to the hospital social worker. -Correct Answer-1. Encourage the client's family to bring
favorite foods.
The client sustained a hot grease burn to the right hand and calls the emergency
room for advice. Which information should the nurse provide to the client?
1. Apply an ice pack to the right hand.
2. Place the hand in cool water.
3. Be sure to rupture any blister formation.
4. Go immediately to the doctor's office. -Correct Answer-2. Place the hand in cool water.
The client is being discharged after being in the burn unit for six (6) weeks. Which
strategies should the nurse identify to promote the client's mental health?
