Integumentary System NCLEX Questions Quizlet
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Question 1 of 5.
The nurse assesses that the client with partial-thickness burns over 50% of the total body surface area (TBSA) has gained weight and has generalized edema after the first 24 hours. The nurse should consider that the edema and weight gain are most likely related to which physiological processes?
A. Elevated serum sodium and potassium levels
B. Increased hemoglobin and hematocrit levels
C. Excess intravenous fluid volume replacement
D. Leakage of plasma into the interstitial space
Explanation: Initially after a severe burn injury there is a loss of capillary integrity and a shift of fluid, sodium, and protein from the intravascular to the interstitial spaces. The body compensates for this interstitial hemoconcentration by retaining more fluid. Sodium is lost due to diuresis, and existing sodium tends to be diluted by an influx of fluid, so serum sodium levels will be decreased, not increased. Hgb and Hct levels may change in severe burns, but they are the result of the fluid shift, not the cause. Fluid volume deficit (not excess) is a major risk during this phase.
Question 2 of 5.
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?
A. The client complains of pain when the medication is administered.
B. The client's potassium level is 3.9 mEq/L and sodium level is 137 mEq/L.
C. The client's ABGs are pH 7.34, PaO2 98, PaCO2 38, and HCO3 20.
D. The client is able to perform active range-of-motion exercises.
Explanation: ABGs showing low HCO3 (20) and pH 7.34 suggest metabolic acidosis, a serious mafenide side effect requiring immediate attention. Pain is expected, electrolytes are normal, and ROM is positive.
Question 3 of 5.
The client is admitted with full-thickness and partial-thickness burns to more than 30% of the body. The nurse is concerned with the client's nutritional status. Which intervention should the nurse implement?
A. Encourage the client's family to bring favorite foods.
B. Provide a low-fat, low-cholesterol diet for the client.
C. Monitor the client's weight weekly in the same clothes.
D. Make a referral to the hospital social worker.
Explanation: Favorite foods increase caloric intake, critical for hypermetabolic burn patients. Low-fat diets are inappropriate, weekly weights are insufficient, and social worker referral is unrelated.
Question 4 of 5.
What is the scientific rationale for placing lift pads under an immobile client?
A. The pads will absorb any urinary incontinence and contain stool.
B. The pads will prevent the client from being diaphoretic.
C. The pads will keep the staff from workplace injuries such as a pulled muscle.
D. The pads will help prevent friction shearing when repositioning the client.
Explanation: Lift pads reduce friction and shear during repositioning, preventing skin breakdown. Absorbent pads address incontinence, diaphoresis is unrelated, and staff safety is secondary.
Question 5 of 5.
The client who is debilitated and has developed multiple pressure ulcers complains to the nurse during a dressing change that he is 'tired of it all.' Which is the nurse's best therapeutic response?
A. These wounds can heal if we get enough protein into you.'
B. Are you tired of the treatments and needing to be cared for?'
C. Why would you say that? We are doing our best.'
D. Have you made out an advance directive to let the HCP know your wishes?'
Explanation: Reflecting the client's feelings encourages discussion, addressing emotional distress. Protein focus, defensiveness, or advance directives dismiss the client's emotions.