NCLEX 10000 Integumentary Disorders QA 2023.

NCLEX 10000 Integumentary Disorders Q&A 2023.When assessing a client with partial-thickness burns over 60% of the body, which finding should the nurse report immediately?

a) Complaints of intense thirst

b) Moderate to severe pain

c) Hoarseness of the voice

d) Urine output of 70 ml the first hour

• Hoarseness of the voice

Correct

Explanation:

Hoarseness is indicative of injury to the respiratory system and could indicate the need for immediate intubation What is the primary goal of nursing care during the emergent phase after a burn injury?

a) Promote wound healing.

b) Replace lost fluids.

c) Control pain.

d) Prevent infection.

• Replace lost fluids.

Correct

Explanation:

During the emergent phase of burn care, one of the most significant problems is hypovolemic shock. The development of hypovolemic shock can lead to impaired blood flow through the heart and kidneys, resulting in decreased cardiac output and renal ischemia. Efforts are directed toward replacing lost fluids and preventing hypovolemic shock.The nurse is evaluating the client's risk for having a pressure sore. Which is the best indicator of risk for the client's developing a pressure sore?

• nutritional status
• orientation status
• circulatory status
• mobility status
• mobility status

Correct

Explanation:

The client's mobility status is the best indicator of risk for development of a pressure sore.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 1 / 3

time. Which of the following statements by the nurse are correct about this type of burn?Select all that apply.

a) This is a severe burn and nerve endings have been destroyed.

b) Rehabilitation and skin grafting will be necessary.

c) Pain medication has been administered orally and was effective.

d) This is a superficial burn, so no pain is present.

e) The child must be monitored for signs of fluid shift

• • 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.Correct

Explanation:

This is an example of a third-degree burn, which is very serious. This child must be carefully monitored for complications. The fact that there is no pain is due to the destruction of the nerve endings. Fluid shift can occur and result in shock. A burn of this degree will also require a long rehabilitation with skin grafting.A client is recovering from an infected abdominal wound. Which foods should the nurse encourage the client to eat to support wound healing and recovery from the infection?

• cheeseburger and french fries
• cheese omelet and bacon
• gelatin salad and tea
• chicken and orange slices
• chicken and orange slices

Correct

Explanation:

Protein and vitamin C are particularly important in promoting wound healing and recovery from infection. A diet high in carbohydrates is also essential. Because the client with an infection commonly does not feel like eating, it is important that what the client eats should be nutritious. Chicken and orange slices would help meet the client's protein and vitamin needs.In an industrial accident, a client who weighs 155 lb (70 kg) sustained full-thickness burns over 40% of his body. He's in the burn unit receiving fluid resuscitation. Which finding shows that the fluid resuscitation is benefiting the client?

a) A urine output consistently above 40 ml/hour (40 mL/hour)

b) Body temperature readings all within normal limits

c) A weight gain of 4 lb (2 kg) in 24 hours

d) An electrocardiogram (ECG) showing no arrhythmias

• A urine output consistently above 40 ml/hour (40 mL/hour)

Correct

Explanation: 2 / 3

In a client with burns, the goal of fluid resuscitation is to maintain a mean arterial blood pressure that provides adequate perfusion of vital structures. If the kidneys are adequately perfused, they will produce an acceptable urine output of at least 0.5 ml/kg/hour. Thus, the expected urine output of a 155-lb (70 kg) client is 35 ml/hour, and a urine output consistently above 40 ml/hour is adequate. Weight gain from fluid resuscitation isn't a goal. In fact, a 4-lb (2 kg) weight gain in 24 hours suggests third spacing.The nurse is caring for a client who has severe burns on the head, neck, trunk, and groin areas. Which position would be most appropriate for preventing contractures?

• semi-Fowler's
• high Fowler's
• supine
• prone
• supine

Correct

Explanation:

Supine in extension is the position most likely to prevent contractures. Clients who have experienced burns will find a flexed position most comfortable. However, flexion promotes the development of contractures.A client comes to the physician's office for treatment of severe sunburn. The nurse takes this opportunity to discuss the importance of protecting the skin from the sun's damaging rays. Which instruction best prevents skin damage?

• "Apply sunscreen even on overcast days."
• "Use a sunscreen with a sun protection factor of 6 or higher."
• "When at the beach, sit in the shade to prevent sunburn."
• "Minimize sun exposure from 1 to 4 p.m., when the sun is strongest."
• "Apply sunscreen even on overcast days."

Correct

Explanation:

Sunscreen should be applied even on overcast days, because the sun's rays are as damaging then as on sunny days.Which of the following would provide the most effective emergency care for a burn victim at the accident site?

a) Pouring cool water over the burned area.

b) Applying clean, dry dressings to the area.

c) Applying a mild antiseptic ointment to the area.

d) Rinsing the area with a warm, mild soap solution.

• Applying clean, dry dressings to the area.

Incorrect Correct response: Pouring cool water over the burned area.

• / 3