Nokea
A nurse is assigned to care for a client who reportedly has no special skincare needs. However, upon assessment, the nurse observes reddened areas over bony prominences. What action should the nurse take?
- A. Document the finding and continue with routine care
- B. Apply a topical antibiotic ointment to the affected areas
- C. Conduct and document an emergency assessment
- D. Perform and document a focused assessment of skin integrity
Correct Answer: D
Rationale: Reddened areas over bony prominences suggest early pressure ulcers, requiring a focused skin integrity assessment to guide interventions.
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A nurse is taking care of a client with severe burns. Which of the following is the best intervention to prevent shock in this client?
- A. Administer dopamine as ordered
- B. Apply medical anti-shock trousers
- C. Infuse IV fluids as indicated
- D. Infuse fresh frozen plasma
Correct Answer: C
Rationale: Infusing IV fluids is the best intervention to prevent hypovolemic shock in burn patients by restoring circulating volume lost due to fluid shifts from severe burns.
Using the rule of nines, calculate the total body surface area (TBSA) burned. Fill in the blank. …………………….%
- A. 36%
- B. 45%
- C. 54%
- D. 63%
Correct Answer: C
Rationale: Using the rule of nines: chest (9%), abdomen (9%), back (18%), bilateral anterior arms (9% total, 4.5% each) = 9 + 9 + 18 + 9 = 45% TBSA.
The nurse is caring for a client with incontinence-associated dermatitis. The nurse should take which action? Select all that apply.
- A. Cleanse the affected area with isopropyl alcohol
- B. Apply zinc oxide to the affected area
- C. Use an incontinence pad instead of a brief
- D. Applying an extra incontinence brief to encapsulate the moisture
- E. Apply a transparent dressing to the affected area
Correct Answer: B, C
Rationale: Zinc oxide protects the skin, and incontinence pads reduce moisture exposure. Alcohol is too harsh, extra briefs trap moisture, and transparent dressings are not suitable for this condition.
The nurse is conducting a community health class on skin changes for older adults. It would be appropriate for the nurse to state which of the following are normal age-related changes? Select all that apply.
- A. Decreased dermal blood flow
- B. Development of actinic lentigo
- C. Degeneration of elastic fibers
- D. Loss of subcutaneous fat
- E. Increased epidermal thickness
Correct Answer: A, B, C, D
Rationale: Normal age-related skin changes include decreased dermal blood flow, actinic lentigo (age spots), degeneration of elastic fibers (leading to wrinkles), and loss of subcutaneous fat (thinner skin). Increased epidermal thickness is not typical; the epidermis thins with age.
The nurse cares for a 29-year-old male in the emergency department (ED)
Item 6 of 6
Nurses' Note
Vital Signs
Assessment
2115: Client brought by emergency medical services (EMS) for a thermal burn injury while setting up a fire outside. His right arm caught fire as some of the lighter fluid he used was on his sweater. The fire then spread to his back and part of his chest. The client has sustained full- thickness burns to his right hand and entire arm. Deep partial thickness burns were observed to his right torso and entire back. The client arrives screaming in pain rating it as 9 on a scale of 0 (no pain) to 10 (severe pain). He endorses no pain in his right arm or hand, stating it feels 'numb.' EMS started a 16-gauge peripheral vascular access device in the left antecubital space.
The nurse assesses the urine output and determines whether the client is meeting the treatment goal when it reaches
- A. 0.10 mL/kg/hr
- B. 0.25 mL/kg/hr
- C. 0.4 mL/kg/hr
- D. 0.5 mL/kg/hr
Correct Answer: D
Rationale: A urine output of 0.5 mL/kg/hr indicates adequate renal perfusion and effective fluid resuscitation in burn patients.