Integumentary NCLEX RN Questions
Home / Nursing & Allied Health Certifications / NCLEX RN / RN Integumentary
Question 1 of 5.
The nurse cares for a client who sustained full-thickness thermal burns to 30% of their total body surface area (TBSA). Which of the following initial laboratory values would be expected?
A. Potassium 5.6 mEq/L (mmol) [3.5-5 mEq/L]
B. Hematocrit 30% (0.30 L/L) [ Male: 42-52% Female: 37-47%, 0.38-0.50 L/L]
C. BUN 14 mg/dL (5.0004 mmol/L)[10-20 mg/dL, 2.1-8.0 mmol/L]
D. Glucose 89 mg/dL (4.94 mmol/L) [70-110 mg/dL, 4.0-11.0 mmol/L]
Explanation: Hyperkalemia (elevated potassium) is expected initially due to cell destruction from burns releasing potassium into the bloodstream.
Question 2 of 5.
Extract:The emergency department (ED) nurse is caring for a client who sustained a witnessed electrical burn Item 1 of 1 Triage Note Triage Vital Signs 1730: A 35-year-old male was brought to the emergency department (ED) by his father after they were working on electrical wiring at a residential house. The client's father witnessed his son grab a wire and sustain a significant 'jolt' for five to ten seconds. The client briefly lost consciousness and was disoriented immediately afterward. The client was immediately placed in the father's car and transported to the ED. A localized burn was noted on the client's right hand. Scant sanguineous drainage noted. The client reports pain of a '6' (0= no pain; 10= severe pain) that is worsened with movement. The client is alert and oriented to place and time; however, he does not recall the situation that brought him to the hospital. Glasgow Coma Scale (GCS) 14. The client reports that he feels like his 'heart is intermittently skipping.'
The nurse is immediately concerned that the client is at risk for developing …………….. as evidenced by the client's ………………
A. carbon monoxide poisoning
B. wound infection
C. cardiac dysrhythmias
D. Glasgow Coma Scale
E. pulse
F. pain level
Explanation: The client's report of feeling like his 'heart is intermittently skipping' indicates a potential cardiac dysrhythmia, which is a serious complication of electrical burns due to the effect of electrical current on the heart. The pulse is the finding that supports this concern.
Question 3 of 5.
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
Explanation: 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.
Question 4 of 5.
The ABCDEs of melanoma identification include which of the following? Select all that apply.
A. Asymmetry: one half does not match the other half
B. Birthmark: cafe au lait spot that does not fade
C. Color: pigmentation is not uniform
D. Diameter: greater than 6 mm
E. Evolving: any change in size, shape, color, elevation, or any new symptom such as bleeding, itching, or crusting
Explanation: The ABCDEs of melanoma are Asymmetry, Border (irregular), Color (varied), Diameter (>6 mm), and Evolving (changes in appearance or symptoms). Birthmark is not part of this mnemonic.
Question 5 of 5.
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
Explanation: 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.