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NURS4500 Final Exam Skin With Questions And Verified Detailed Answers
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NURS4500 Final Exam Skin With Questions AndVerified Detailed Answers 2024-2025
The client comes to the emergency department in excruciating pain and relates that he
had an accident in which a pot of boiling hot water spilled onto his lower extremities. On
examination, the skin is blistered, mottled red, and both feet are edematous. The nurse
should document the depth of this burn as
1. Superficial partial thickness.
2. Deep partial thickness.
3. Full thickness.
4. First degree. - Answer 2. Deep partial thickness.
The client is being transferred from a community hospital to a burn center with
full-thickness burns to 40% of the body, including both legs. Which measure should be
instituted before the transfer?
1. A 22-gauge intravenous line with normal saline infusing.
2. Wounds covered with moist sterile dressings.
3. No intravenous pain medication.
4. Adequate peripheral circulation to both feet ensured. Answer 4. Adequate peripheral
circulation to both feet ensured.
The client has sustained full-thickness burns to 65% of the body, including the chest.
Once a patent airway has been established for the client, which collaborative
intervention is priority?
1. Replace fluids and electrolytes.
2. Prevent contractures of extremities.
,3. Monitor urine output hourly.
4. Prepare to assist with an escharotomy. Answer 1. Replace fluids and electrolytes.
The nurse is applying mafenide acetate (Sulfamylon), a sulfa antibiotic cream, to a
client's lower extremity burn. Which assessment data would require immediate attention
by the nurse?
1. The client states he is having pain and is being medicated for it.
2. The client's potassium is 3.9 mEq/L and sodium is 137 mEq/L.
3. The client's ABGs are pH 7.34, PaO2 98, PaCO2 38, and HCO3 20.
4. The client can perform active range-of-motion exercises. -Answer 3. The client's
ABGs are pH 7.34, PaO2 98, PaCO2 38, HCO3 20.
The client is scheduled to receive a xenograft to a left lower-leg burn. The client asks
the nurse, "What is a xenograft?" Which statement by the nurse would be the best
response?
1. "The doctor will graft skin from your back to your leg.
2. "The graft will be taken from a donor and will cover your burn skin."
3. "It will be taken out from an animal, probably from a pig."
4. "I think you should ask your doctor about the graft." - Answer 3. "The graft will be
taken from an animal, probably a pig."
The ICU burn nurse is developing a nursing care plan for a client who has experienced
severe fullthickness and deep partialthickness burns over half the body. Which client
problem is the highest priority?
1. High risk for infection.
2. Ineffective coping.
3. Impaired physical mobility.
, 4. Knowledge deficit. -Answer 1. High risk for infection.
The nurse selects the nursing diagnosis "impaired skin integrity related to open burn
wounds." Which intervention is appropriate for this nursing diagnosis?
1. Administer analgesia before pain becomes severe.
2. Bathe the client's wounds, body, and hair daily.
3. Screen visitors for respiratory infection.
4. Encourage visitors to bring plants and flowers. -Answer 2. Bathe the client's wounds,
body, and hair daily.
Select all that apply. Which nursing interventions should be included for the client who
has full-thickness and deep partial-thickness burns to 50% of the body?
1. Perform meticulous hand hygiene.
2. Use sterile gloves for wound care.
3. Wear gown and mask during procedures.
4. Change invasive lines once a week.
5. Administer antibiotics as prescribed. - Answer 1. Perform meticulous hand hygiene.
The nurse is caring for a client with deep partial-thickness and full-thickness burns
to the chest area. Which assessment data would require notification of the health-care
provider?
1. The client reports pain and rates it at 10 on a scale of 1-10.
2. The client's pulse oximeter reading is 95%.
3. The client has T 100.4°F, P 100, R 24, and BP 102/60.
4. The client's urinary output is 50 mL in two (2) hours. -Answer 4. The client's urinary
output is 50 mL in two (2) hours.
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