Nokea
The nurse documents the presence of a skin lesion as a 'palpable solid mass measured at 1 cm.' What types of skin lesions might this describe? Select all that apply.
- A. Macule
- B. Patch
- C. Plaque
- D. Nodule
- E. Bulla
- F. Pustule
Correct Answer: C, D
Rationale: A palpable solid mass of 1 cm could be a plaque (elevated, >1 cm) or nodule (solid, deeper, 0.5-2 cm). Macules and patches are flat, bullae are fluid-filled, and pustules contain pus.
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Which of the following would the nurse recognize as an accurate statement regarding pressure ulcers? Select all that apply.
- A. In a stage Il pressure ulcer, part of the dermis and epidermis are lost.'
- B. In a stage I pressure ulcer, there is a loss of integrity of the epidermis only.'
- C. In a stage Ill pressure ulcer, a deep tissue injury can expose fat.'
- D. In a stage IV pressure ulcer, the base of the wound is covered by eschar.'
- E. Stage Ill involves extensive tissue damage and can lead to bone and muscle involvement.'
Correct Answer: A, C
Rationale: Stage II involves partial loss of dermis and epidermis, and Stage III can expose fat. Stage I is non-blanchable redness, Stage IV may expose bone/muscle, and eschar is not always present.
Place the following actions in the order in which they need to be performed, starting with the highest priority action.
- A. Initiate a large-bore peripheral vascular access device
- B. Perform a respiratory assessment and inspect the client's nose and mouth
- C. Administer prescribed intravenous (IV) pain medication
- D. Administer prescribed intravenous (IV) fluids
- E. Perform wound care to the affected area(s)
Correct Answer: B, A, D, C, E
Rationale: Respiratory assessment is first to ensure airway patency, followed by IV access and fluids for resuscitation, pain medication for comfort, and wound care last.
The nurse is performing a head-to-toe assessment for an older adult. Which finding from the integumentary assessment does the nurse recognize as a normal age-related change:
- A. Moist skin
- B. Increased nail growth
- C. Dry, itchy skin
- D. Increased skin pigmentation
Correct Answer: C
Rationale: Dry, itchy skin is a normal age-related change due to decreased oil production and skin thinning.
A nurse is caring for a client at risk of developing pressure ulcers. Which of the following is an intrinsic risk factor that contributes to this increased risk?
- A. Shearing
- B. Friction
- C. Impaired tissue perfusion
- D. Pressure
Correct Answer: C
Rationale: Impaired tissue perfusion is an intrinsic risk factor because it originates within the body, affecting blood flow and tissue oxygenation, which can lead to pressure ulcer development. Shearing, friction, and pressure are extrinsic factors as they are external forces acting on the skin.
The nurse cares for a 29-year-old male in the emergency department (ED)
Item 5 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 should plan to obtain a prescription for ………………….. to restore circulating volume. The ……………………… will be used to determine the 24-hour fluid requirement. To measure the effectiveness of the fluid replacement, the nurse plans to …………………………..
- A. 0.45% saline
- B. Dextrose 5% Water (D5W)
- C. Lactated ringers
- D. Parkland formula
- E. pulmonary function tests
- F. TNM staging
- G. insert an indwelling urinary catheter
Correct Answer: C, D, G
Rationale: Lactated Ringers restores circulating volume, the Parkland formula calculates fluid needs, and a urinary catheter monitors output to assess fluid replacement effectiveness.