Integumentary NCLEX Questions
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Question 1 of 5.
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
Explanation: 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 burnâ€â€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.
Question 2 of 5.
The client with full-thickness burns to 40% of the body, including both legs, is being transferred from a community hospital to a burn center. Which measure should be instituted before the transfer?
A. A 22-gauge intravenous line with normal saline infusing.
B. Wounds covered with moist sterile dressings.
C. No intravenous pain medication.
D. Ensure adequate peripheral circulation to both feet.
Explanation: Ensuring peripheral circulation prevents ischemic complications during transfer. A 22-gauge IV is too small for major burns, moist dressings are inappropriate for full-thickness burns, and IV pain medication is needed.
Question 3 of 5.
Which nursing interventions should be included for the client who has full-thickness and deep partial-thickness burns to 50% of the body? Select all that apply.
A. Perform meticulous hand hygiene.
B. Use sterile gloves for wound care.
C. Wear gown and mask during procedures.
D. Change central lines once a week.
E. Administer antibiotics as prescribed.
Explanation: Hand hygiene, sterile gloves, gown/mask, and antibiotics prevent infection in extensive burns. Weekly central line changes are not standard; daily assessment is preferred.
Question 4 of 5.
The nurse is caring for a client who has developed stage IV pressure ulcers on the left trochanter and coccyx. Which collaborative problem has the highest priority?
A. Impaired cognition.
B. Altered nutrition.
C. Self-care deficit.
D. Altered coping.
Explanation: Altered nutrition is critical in stage IV ulcers to support wound healing. Cognition, self-care, and coping are secondary in advanced wounds.
Question 5 of 5.
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.
Explanation: Fever in a client with pressure ulcers suggests infection, requiring urgent assessment. Quadriplegia, weakness, and dissatisfaction are less acute.