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When assessing a burn victim's skin the nurse notices the entire right and left upper extremities are red, moist, weeping, and blistered. How should the nurse document the degree and total body surface area (TBSA) burned?
- A. First-degree burn on 9% TBSA
- B. Partial-thickness burn on 18% TBSA
- C. Partial-thickness burn on 27% TBSA
- D. Full-thickness burn on 36% TBSA
Correct Answer: B
Rationale: Partial-thickness burns damage the dermis and epidermis, often resulting in loss of epidermis and/or blistering. Each entire upper extremity is blistered. Approximately 18% of the TBSA has a partial-thickness burn (9% TBSA per each upper extremity). This is not a first-degree burn—In a first-degree burn the skin may appear red but intact, no weeping, and no blistering. With full-thickness burns there would be loss of tissue and a black or white charred/waxy appearance to the remaining tissues.
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There is an outbreak of scabies in a long-term care facility. Which instruction should the infection control nurse provide to all client care staff concerning the transmission of this parasitic infection?
- A. Use only hand-washing foam when caring for clients with scabies.
- B. Wear gloves when providing hands-on care for a client with scabies.
- C. Wash all linen and clothes in cold water and dry them outside in the sun.
- D. Instruct clients to use plastic eating utensils for meals.
Correct Answer: B
Rationale: Gloves prevent scabies transmission during direct contact. Hand-washing foam is insufficient, hot water washing is needed, and plastic utensils are irrelevant.
Before leaving the room, which of the following nursing actions should the nurse perform?
- A. The nurse straightens the client's linens.
- B. The nurse informs the client when leaving the room.
- C. The nurse offers to give the client a back rub.
- D. The nurse shares some current events with the client.
Correct Answer: B
Rationale: Informing the client when leaving reduces anxiety and enhances safety.
Which response by the nurse is best at this time?
- A. I'm sure you will look absolutely gorgeous.
- B. I didn't think you were unattractive before.
- C. Your face is swollen with bruises around the eyes.
- D. Your personality is more important than your looks.
Correct Answer: C
Rationale: An honest response about expected swelling prepares the client for recovery.
If the physician wants to check the client's intraocular pressure (IOP), which instrument should the nurse have available?
- A. Ophthalmoscope
- B. Tonometer
- C. Retinoscope
- D. Speculum
Correct Answer: B
Rationale: A tonometer measures intraocular pressure, essential for glaucoma assessment.
The nurse is caring for clients on a medical unit. After the shift report, which client should the nurse assess first?
- A. The 34-year-old client who is quadriplegic and cannot move his arms.
- B. The elderly client diagnosed with a CVA who is weak on the right side.
- C. The 78-year-old client with pressure ulcers who has a temperature of 102.3°F.
- D. The young adult who is unhappy with the care that was provided last shift.
Correct Answer: C
Rationale: Fever in a client with pressure ulcers suggests infection, requiring urgent assessment. Quadriplegia, weakness, and dissatisfaction are less acute.