NCLEX-PN
Integumentary NCLEX Questions Questions
Extract:
Question 1 of 5
A 28-year-old man received severe burns of the chest, abdomen, back, legs, and hands when the house caught fire. In the emergency room, a nasogastric tube was inserted, and the client was ordered NPO. What is the primary reason for the nurse to keep this client NPO?
Correct Answer: C
Rationale: Severe burns predispose clients to paralytic ileus due to stress and fluid shifts, so keeping the client NPO prevents complications until bowel function returns.
Question 2 of 5
A client who was severely burned goes to the Hubbard tank daily. Tanking sessions are limited to a half hour for which reason?
Correct Answer: C
Rationale: Prolonged soaking in the Hubbard tank can lead to electrolyte dilution, risking imbalances in burn clients who are already prone to fluid and electrolyte shifts.
Question 3 of 5
The nurse is teaching a class on the prevention of cancer. Which information should be included regarding how to reduce the risk of skin cancer?
Correct Answer: A
Rationale: Avoiding prolonged sun exposure reduces ultraviolet radiation damage, a primary risk factor for skin cancer.
Question 4 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?
Correct Answer: B
Rationale: 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 burn—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 5 of 5
The client sustained partial- and full-thickness burns to the anterior left and right arms, anterior chest and abdominal area, and anterior left leg. Using the Rule of Nines, what is the estimated extent of this injury that the nurse should document? % (Record your answer as a whole number.)
Correct Answer: A
Rationale: According to the Rule of Nines, this client sustained injuries on about 36% of the body surface: right arm is 4.5%; left arm is 4.5%; left leg is 9%; anterior chest and abdomen are 18%.