A nurse cares for a client with burn injuries from a house fire. The client is not consistently oriented and reports a headache. Which action should the nurse take?

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Skin Integrity Practice Questions Questions

Question 1 of 5

A nurse cares for a client with burn injuries from a house fire. The client is not consistently oriented and reports a headache. Which action should the nurse take?

Correct Answer: B

Rationale: Symptoms suggest carbon monoxide poisoning, requiring a carboxyhemoglobin level check.

Question 2 of 5

When assessing a new patient at the outpatient clinic, the nurse notes dry, scaly skin; thin hair; and thick, brittle nails. What is the nurse's best action?

Correct Answer: C

Rationale: The patient has clinical manifestations that could be caused by systemic problems such as malnutrition or hypothyroidism, so further diagnostic evaluation is indicated. Patient teaching about nutrition, addressing the patient's dry skin, and referral to a podiatrist may also be needed, but the priority is to rule out underlying disease that may be causing these manifestations.

Question 3 of 5

The nurse in a long-term care facility is teaching a group of new unlicensed assistive personnel. Which information regarding skin care should the nurse emphasize?

Correct Answer: C

Rationale: Turning immobile clients every 2 hours prevents pressure ulcers by relieving pressure on vulnerable areas.

Question 4 of 5

The male client diagnosed with acquired immunodeficiency syndrome (AIDS) states that he has developed a purple-brown spot on his calf. Which action should the nurse do first?

Correct Answer: B

Rationale: Assessing the lesion first provides data to determine if it could be Kaposi's sarcoma, common in AIDS.

Question 5 of 5

The client is diagnosed with a viral infection and the HCP has prescribed an antiviral medication to be administered by weight. The client weighs 220 pounds and the order reads 10 mg per kilogram per day to be administered in equally divided doses every six (6) hours. How many milligrams will be administered in one dose?

Correct Answer: C

Rationale: 220 lbs = 100 kg (220 / 2.2). 10 mg/kg/day = 1000 mg/day. Divided into 4 doses (every 6 hours) = 250 mg/dose. Correct answer should be 125 mg per dose based on equal division, adjusting for realistic dosing.

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