SAUNDERS HESI MED SURG EXAM QUESTIONS AND 100%
CORRECT ANSWERS LATEST UPDATE
The nurse is conducting a lecture on the principles of first aid and is discussing the
interventions for snakebite to an extremity. The nurse should instruct those present in
the session that the first priority intervention in the event of this occurrence is which
action?
1. Immobilize the affected extremity.
2. Remove jewelry and constricting clothing from the victim.
3. Place the extremity lower than the heart level
4. Move the victim to a safe location away from the snake and allow rest for the victim. -
Answer 4
The priority in treating a snake bite is to move the victim to a safe location away from the
snake and allowing the victim to rest in order to minimize the spreading of the venom.
Jewelry and constricting clothing are then removed before swelling begins. The
extremity is immobilized and kept at heart level; both of these actions reduce the spread
of the venom. The victim is kept warm and as calm as possible. Stimulants like alcohol or
caffeinated drinks are not administered to the victim because these drugs may
accelerate the absorption of the venom. The victim should be taken to an emergency
facility as soon as possible.
A client calls the emergency department and tells the nurse that he came in direct
contact with poison ivy shrubs. The client tells the nurse that he cannot see anything on
the skin and asks the nurse what to do. The nurse should make which response?
1. "Come to the emergency department."
2. "Immediately apply calamine lotion to the exposed parts of the skin."
3. "Immediately take a shower and wash, using abundant suds; rinse, repeating the
washing and rinsing several times"
,4. "Do nothing if you cannot see anything on your skin." - ANS 3
When an individual comes in contact with a poison
ivy plant, the sap of the plant forms an invisible film on the human skin. The client should
be taught to wash the area by showering immediately and to soap the skin several times
and rinse each time in running water. Washing off the poison ivy sap will reduce the
chance of irritation. Calamine lotion
may be one product suggested for use if dermatitis
develops. The client does not need to be taken to the emergency department at this
stage.
A client is admitted to the hospital for treatment of acute cellulitis of the lower left leg.
While performing the admission assessment, the nurse expects to find which of the
following?
1. An inflammation of the epidermis alone
2. A skin infection of the dermis and underlying hypodermis
3. An acute superficial infection of the dermis and lymphatics
4. Staphylococcal epidermal and lymphatic infection - Answer 2
Cellulitis is an infection of the dermis and underlying hypodermis that causes deep red
erythema without distinct borders and that spreads widely through tissue spaces. Skin
is erythematous, edematous, tender, and at times nodular. Erysipelas is an acute
superficial rapidly spreading inflammation of the dermis and lymphatics. The infection is
not superficial but extends deeper than the epidermis.
The clinic nurse assesses a client's skin with psoriasis who has been receiving a new
topical treatment for 2 months. The nurse identifies which of the following findings as an
improvement in the manifestations of psoriasis? (SELECT ALL THAT APPLY)
1. Striae present
2. Radial pulses palpable
,3. No ecchymosis noted on the extremities
4. Thinner and decreased number of reddish papules
5. Very few silvery-white scaly patches of lesions in the arms - Response 4, 5
Skin lesions of psoriasis are in the form of erythematous, crusted, thickened papules or
plaques with silvery-white scaling on top. A disappearance of these skin lesions or at
least a decrease in severity is improvement. The following conditions - presence of
striae or stretch marks, palpable pulses, or absence of ecchymosis - are unrelated to
the disorder.
Herpes zoster (shingles) is the diagnosis documented in the client's chart by the health
care provider. Based on an understanding of the etiology of this disorder, the clinic
nurse decides this definitive diagnosis was provided by which of the following
diagnostic tests?
1. Positive patch test
2. Positive culture results
3. Abnormal biopsy results
4. Wood's light examination indicative of infection - Answer 2
In the classic presentation of herpes zoster, the clinical examination is diagnostic.
However, viral culture of the lesion provides a definitive diagnosis. Herpes zoster, or
shingles, is caused by reactivation of the varicella-zoster virus that causes chickenpox.
A patch test is a skin test that involves the administration of an allergen to the surface of
the skin to identify specific allergies. A biopsy would yield the cytological examination of
tissue. In Wood's light examination, the skin is observed under ultraviolet light in order
to locate superficial infections of the skin.
The client presents to the clinic for follow-up care after a skin biopsy of a suspicious
lesion was performed 1 week ago. The biopsy report indicates the lesion is a type of
melanoma. The nurse identifies that melanoma has which characteristics? (SELECT ALL
THAT APPLY.)
,1. The lesion is tender to the touch.
2. The lesion is highly metastatic.
3. The lesion is a nevus that has changes in color.
4. Skin around the lesion is red and warm.
5. The lesion is on an area of the body exposed to direct sun light when outdoors. -
>Selections 2 and 3 are correct
Melanomas are pigmented malignant lesions originating in the melanin-producing cells
of the epidermis. Melanomas cause changes in a nevus (mole), including color and
borders. This skin cancer is highly metastatic, and a person's survival depends on early
diagnosis and treatment. Melanomas are not painful or accompanied by sign of
inflammation. Although sun exposure increases the risk of melanoma, lesions are most
commonly found on the upper back and legs and on
the soles and palms of dark-skinned individuals.
For a lesion that has been diagnosed as basal cell carcinoma, which findings does the
nurse most likely expect to note? (SELECT ALL THAT APPLY.)
1. An irregularly shaped lesion
2. A small papule with a dry, rough scale
3. A firm, nodular lesion topped with crust
4. A pearly papule with a central crater and a waxy border
5. Location in the bald area on top of the head exposed to the outdoor UV radiation -
Answers 4, 5
Basal cell carcinoma presents as a pearly papule bearing
a central crater and rolled waxy border. Exposure to ultraviolet sunlight is a major risk
factor. A melanoma is an irregularly shaped pigmented papule or plaque with a red-,
white-, or blue-toned color. Actinic keratosis, a premalignant lesion, appears as a small
macule or papule with a dry, rough, adherent yellow or brown scale. Squamous cell
carcinoma is a firm, nodular lesion topped with a crust or a central area of ulceration.
,A client is admitted to the emergency department with frostbite of the right hand. What
does the nurse note when assessing the client's hand?
1. A pink, edematous hand
2. Fiery red skin with edema in the nail beds
3. Black fingertips surrounded by an erythematous rash
4. A white color to the skin, which is insensitive to touch - Answer 4
White or
blue color; the skin will be hard, cold, and insensitive to touch. As thawing occurs,
flushing of the skin, the development of blisters or blebs, or tissue edema appears.
Options 1, 2, and 3 are incorrect.
The evening nurse reviews the nursing documentation in a client's chart and notes that
the day nurse has documented that the client has a stage II pressure ulcer in the sacral
area. Which finding would the nurse expect to note on assessment of the client's sacral
area?
1. Intact skin
2. Full-thickness skin loss
3. Exposed bone, tendon, or muscle
4. Partial-thickness skin loss of the dermis - Answer 4
In stage II pressure ulcer, the skin is not intact.
Partial-thickness skin loss of the dermis has occurred. It presents as a shallow open
ulcer with a redpink wound bed, without slough. It may also present as an intact or
open/ruptured serum-filled blister. The skin is intact in stage I. Full-thickness skin loss
occurs in stage III. Exposed bone, tendon, or muscle is present in stage IV.
The adult client had been burned in an explosion: The initial burn to the client's face and
had received circumferential burns to the lower half of both arms, as well as the upper
, half of the anterior torso. Burning clothes on the client's body caused the client to run,
resulting in burns to the posterior surface of the head and the upper half of the posterior
torso.
Using the rule of nines, the extent of the burn injury would be
1. 18%
2. 24%
3. 36%
4. 48% - Answer 3
Based on the rule of nines, with the first burn
Anterior head is 4.5%, the anterior half of the torso is 9%, and lower halves of both arms
are 9% each. The second degree involved posterior half of the head, which also is 4.5%,
and the upper half of posterior torso, 9%. Total was 36%.
The nurse is planning care for a burn client who is scheduled to undergo an
escharotomy procedure for a third-degree circumferential arm burn. The nurse
recognizes that which finding
represents the expected therapeutic effect of the
escharotomy?
1. Return of distal pulses
2. Brisk bleeding from the site
3. Decreasing edema formation
4. Formation of granulation tissue - Answer 1
Escharotomies relieve the compartment syndrome that may develop when oedema
forms under nondistensible eschar in a circumferential third-degree burn. The
escharotomy releases the tourniquet-like compression around the arm. Escharotomies
are performed through avascular eschar to subcutaneous fat. Although bleeding may
occur
CORRECT ANSWERS LATEST UPDATE
The nurse is conducting a lecture on the principles of first aid and is discussing the
interventions for snakebite to an extremity. The nurse should instruct those present in
the session that the first priority intervention in the event of this occurrence is which
action?
1. Immobilize the affected extremity.
2. Remove jewelry and constricting clothing from the victim.
3. Place the extremity lower than the heart level
4. Move the victim to a safe location away from the snake and allow rest for the victim. -
Answer 4
The priority in treating a snake bite is to move the victim to a safe location away from the
snake and allowing the victim to rest in order to minimize the spreading of the venom.
Jewelry and constricting clothing are then removed before swelling begins. The
extremity is immobilized and kept at heart level; both of these actions reduce the spread
of the venom. The victim is kept warm and as calm as possible. Stimulants like alcohol or
caffeinated drinks are not administered to the victim because these drugs may
accelerate the absorption of the venom. The victim should be taken to an emergency
facility as soon as possible.
A client calls the emergency department and tells the nurse that he came in direct
contact with poison ivy shrubs. The client tells the nurse that he cannot see anything on
the skin and asks the nurse what to do. The nurse should make which response?
1. "Come to the emergency department."
2. "Immediately apply calamine lotion to the exposed parts of the skin."
3. "Immediately take a shower and wash, using abundant suds; rinse, repeating the
washing and rinsing several times"
,4. "Do nothing if you cannot see anything on your skin." - ANS 3
When an individual comes in contact with a poison
ivy plant, the sap of the plant forms an invisible film on the human skin. The client should
be taught to wash the area by showering immediately and to soap the skin several times
and rinse each time in running water. Washing off the poison ivy sap will reduce the
chance of irritation. Calamine lotion
may be one product suggested for use if dermatitis
develops. The client does not need to be taken to the emergency department at this
stage.
A client is admitted to the hospital for treatment of acute cellulitis of the lower left leg.
While performing the admission assessment, the nurse expects to find which of the
following?
1. An inflammation of the epidermis alone
2. A skin infection of the dermis and underlying hypodermis
3. An acute superficial infection of the dermis and lymphatics
4. Staphylococcal epidermal and lymphatic infection - Answer 2
Cellulitis is an infection of the dermis and underlying hypodermis that causes deep red
erythema without distinct borders and that spreads widely through tissue spaces. Skin
is erythematous, edematous, tender, and at times nodular. Erysipelas is an acute
superficial rapidly spreading inflammation of the dermis and lymphatics. The infection is
not superficial but extends deeper than the epidermis.
The clinic nurse assesses a client's skin with psoriasis who has been receiving a new
topical treatment for 2 months. The nurse identifies which of the following findings as an
improvement in the manifestations of psoriasis? (SELECT ALL THAT APPLY)
1. Striae present
2. Radial pulses palpable
,3. No ecchymosis noted on the extremities
4. Thinner and decreased number of reddish papules
5. Very few silvery-white scaly patches of lesions in the arms - Response 4, 5
Skin lesions of psoriasis are in the form of erythematous, crusted, thickened papules or
plaques with silvery-white scaling on top. A disappearance of these skin lesions or at
least a decrease in severity is improvement. The following conditions - presence of
striae or stretch marks, palpable pulses, or absence of ecchymosis - are unrelated to
the disorder.
Herpes zoster (shingles) is the diagnosis documented in the client's chart by the health
care provider. Based on an understanding of the etiology of this disorder, the clinic
nurse decides this definitive diagnosis was provided by which of the following
diagnostic tests?
1. Positive patch test
2. Positive culture results
3. Abnormal biopsy results
4. Wood's light examination indicative of infection - Answer 2
In the classic presentation of herpes zoster, the clinical examination is diagnostic.
However, viral culture of the lesion provides a definitive diagnosis. Herpes zoster, or
shingles, is caused by reactivation of the varicella-zoster virus that causes chickenpox.
A patch test is a skin test that involves the administration of an allergen to the surface of
the skin to identify specific allergies. A biopsy would yield the cytological examination of
tissue. In Wood's light examination, the skin is observed under ultraviolet light in order
to locate superficial infections of the skin.
The client presents to the clinic for follow-up care after a skin biopsy of a suspicious
lesion was performed 1 week ago. The biopsy report indicates the lesion is a type of
melanoma. The nurse identifies that melanoma has which characteristics? (SELECT ALL
THAT APPLY.)
,1. The lesion is tender to the touch.
2. The lesion is highly metastatic.
3. The lesion is a nevus that has changes in color.
4. Skin around the lesion is red and warm.
5. The lesion is on an area of the body exposed to direct sun light when outdoors. -
>Selections 2 and 3 are correct
Melanomas are pigmented malignant lesions originating in the melanin-producing cells
of the epidermis. Melanomas cause changes in a nevus (mole), including color and
borders. This skin cancer is highly metastatic, and a person's survival depends on early
diagnosis and treatment. Melanomas are not painful or accompanied by sign of
inflammation. Although sun exposure increases the risk of melanoma, lesions are most
commonly found on the upper back and legs and on
the soles and palms of dark-skinned individuals.
For a lesion that has been diagnosed as basal cell carcinoma, which findings does the
nurse most likely expect to note? (SELECT ALL THAT APPLY.)
1. An irregularly shaped lesion
2. A small papule with a dry, rough scale
3. A firm, nodular lesion topped with crust
4. A pearly papule with a central crater and a waxy border
5. Location in the bald area on top of the head exposed to the outdoor UV radiation -
Answers 4, 5
Basal cell carcinoma presents as a pearly papule bearing
a central crater and rolled waxy border. Exposure to ultraviolet sunlight is a major risk
factor. A melanoma is an irregularly shaped pigmented papule or plaque with a red-,
white-, or blue-toned color. Actinic keratosis, a premalignant lesion, appears as a small
macule or papule with a dry, rough, adherent yellow or brown scale. Squamous cell
carcinoma is a firm, nodular lesion topped with a crust or a central area of ulceration.
,A client is admitted to the emergency department with frostbite of the right hand. What
does the nurse note when assessing the client's hand?
1. A pink, edematous hand
2. Fiery red skin with edema in the nail beds
3. Black fingertips surrounded by an erythematous rash
4. A white color to the skin, which is insensitive to touch - Answer 4
White or
blue color; the skin will be hard, cold, and insensitive to touch. As thawing occurs,
flushing of the skin, the development of blisters or blebs, or tissue edema appears.
Options 1, 2, and 3 are incorrect.
The evening nurse reviews the nursing documentation in a client's chart and notes that
the day nurse has documented that the client has a stage II pressure ulcer in the sacral
area. Which finding would the nurse expect to note on assessment of the client's sacral
area?
1. Intact skin
2. Full-thickness skin loss
3. Exposed bone, tendon, or muscle
4. Partial-thickness skin loss of the dermis - Answer 4
In stage II pressure ulcer, the skin is not intact.
Partial-thickness skin loss of the dermis has occurred. It presents as a shallow open
ulcer with a redpink wound bed, without slough. It may also present as an intact or
open/ruptured serum-filled blister. The skin is intact in stage I. Full-thickness skin loss
occurs in stage III. Exposed bone, tendon, or muscle is present in stage IV.
The adult client had been burned in an explosion: The initial burn to the client's face and
had received circumferential burns to the lower half of both arms, as well as the upper
, half of the anterior torso. Burning clothes on the client's body caused the client to run,
resulting in burns to the posterior surface of the head and the upper half of the posterior
torso.
Using the rule of nines, the extent of the burn injury would be
1. 18%
2. 24%
3. 36%
4. 48% - Answer 3
Based on the rule of nines, with the first burn
Anterior head is 4.5%, the anterior half of the torso is 9%, and lower halves of both arms
are 9% each. The second degree involved posterior half of the head, which also is 4.5%,
and the upper half of posterior torso, 9%. Total was 36%.
The nurse is planning care for a burn client who is scheduled to undergo an
escharotomy procedure for a third-degree circumferential arm burn. The nurse
recognizes that which finding
represents the expected therapeutic effect of the
escharotomy?
1. Return of distal pulses
2. Brisk bleeding from the site
3. Decreasing edema formation
4. Formation of granulation tissue - Answer 1
Escharotomies relieve the compartment syndrome that may develop when oedema
forms under nondistensible eschar in a circumferential third-degree burn. The
escharotomy releases the tourniquet-like compression around the arm. Escharotomies
are performed through avascular eschar to subcutaneous fat. Although bleeding may
occur
