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RN Nursing School · Med-Surg · 101 questions

Integumentary Disorders practice questions

Every question below is free to read with its full rationale. For timed sets, the rest of the bank and progress tracking on Integumentary Disorders, practise in the app.

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  1. 1Based on the patient's current vital signs and lab values, which nursing action should be prioritized first?Answer →
  2. 2According to the Parkland formula, fluid replacement should be completed within 24 hours from the time of the burn. Your nursing order reads to administer "4mL x TBSA x kg". Following the Parkland formula and Rule of Nines, calculate the first 8 hour IV rate to be administered to a 176 lb female with burns to the anterior trunk, anterior right leg and posterior right leg.Answer →
  3. 3A nurse cares for a client at high risk for pressure injuries. Which intervention is most effective for prevention?Answer →
  4. 4A camp nurse cares for a child with contact dermatitis caused by poison ivy. Which is the nurse's first action?Answer →
  5. 5A 45-year-old male presents to the emergency department with burns after a house fire. He has partial-thickness burns covering 27% of his total body surface area, a circumferential burn of his right arm, and a history of uncontrolled diabetes. Which of the following factors indicate that this patient should be referred to a burn center? (Select all that apply)Answer →
  6. 6In addition to calling 911, what is the appropriate nursing response when a client calls the telehealth nurse to report being bitten on the arm by an unknown type of snake?Answer →
  7. 7A nurse is providing education to a patient with contact dermatitis from a nickel watch band. Which instruction is the priority?Answer →
  8. 8A 47-year-old female patient was brought to the emergency room with a diagnosis of a radiation burns, from radiation for thyroid cancer. As the nurse caring for the client, the most important and immediate response is to completely assess which body systems first?Answer →
  9. 9According to the Parkland formula, fluid replacement should be completed within 24 hours from the time of the burn. Your nursing order reads to administer "2mL X TBSA x kg". Following the Parkland formula and Rule of Nines, calculate the second 16 hour IV rate to be administered to a 176 lb male with burns to the posterior torso and posterior left leg.Answer →
  10. 10A nurse is providing teaching to a client about risk factors for developing glaucoma. Which of the following risk factors should the nurse include in the teaching?Answer →
  11. 11A client is prescribed gentamicin for treatment for a burn. Which of the following is a common side effect of the medication?Answer →
  12. 12Which breakfast selection should the nurse encourage a client to eat who is hospitalized with partial-thickness and full-thickness burns to both legs?Answer →
  13. 13A nurse is caring for a hospitalized patient who has severe facial burns and signs of increasing laryngeal edema. Which intervention is most appropriate to anticipate and advocate for to prevent total airway obstruction?Answer →
  14. 14A nurse is assessing a client who has had an aquathermia pad applied to the lower back for muscle spasms for the past 30 minutes. Which of the following findings at the application site would be the first indication that the client is experiencing a superficial burn injury?Answer →
  15. 15A client has just been told that they have Stage 1 malignant melanoma. The nurse caring for this client should anticipate that the client will undergo what treatment?Answer →
  16. 16A patient was in an automobile accident and received a wound across the nose and cheek. After surgery to repair the wound, the patient says, "I am so ugly now." Based on this statement, which psychosocial problem will the nurse plan to address?Answer →
  17. 17A client on mechanical ventilation with extensive burns covering 30% of total body surface area requires nutritional support. Which of the following is the most appropriate initial intervention to address the client's increased metabolic demands?Answer →
  18. 18A nurse is caring for a client with a large burn wound being treated with topical silver nitrate. Which of the following laboratory values should the nurse monitor due to potential systemic effects of the medication? (Select all that apply)Answer →
  19. 19Which statement accurately describes a developmental consideration when assessing skin integrity of clients?Answer →
  20. 20A patient is suspected to have a stage 2 pressure injury on the sacrum. Which dressing would be most appropriate to maintain a moist environment and aid in healing?Answer →
  21. 21A child is admitted with circumferential burns of the left arm. Following the initial assessment, what is the most urgent intervention the nurse should anticipate to prevent complications such as compartment syndrome?Answer →
  22. 22Nurse in an emergency room is caring a client who sustained partial-thickness burns to both lower legs, chest, face, and both forearms. Which of the following is the priority action the nurse should take?Answer →
  23. 23A medication that causes extreme photosensitivity was recently prescribed for a client. In providing discharge instructions, the nurse should teach this client to increase intake of which foods?Answer →
  24. 24The nurse teaches a client about increasing vitamin A intake. Which statement by the client requires further action?Answer →
  25. 25A nurse is assessing a patient who reports a chronic, "unbearable" itch on their arms and legs. Which finding is most likely associated with long-standing atopic dermatitis?Answer →
  26. 26A nurse is caring for a client in hypovolemic shock due to extensive fluid loss from severe burns. The client's vital signs are: heart rate 128 bpm, blood pressure 82/54 mm Hg, respiratory rate 28 breaths per minute, and urine output 15 mL/hr. Which intervention should the nurse prioritize to effectively manage this client's condition?Answer →
  27. 27A nurse educator is working with the staff to decrease skin tissue injuries to clients on the medical-surgical unit. Which of the following practices will decrease friction injuries?Answer →
  28. 28A client who had a cerebral vascular accident (CVA) is paralyzed on the left side of the body and has developed a Stage II pressure injury on the left hip. Which nursing problem best describes this client's current health status?Answer →
  29. 29A nurse is assessing a patient with a stage III pressure ulcer. What assessment of the ulcer would be expected?Answer →
  30. 30A nurse cares for a client at high risk for pressure injuries. Which intervention is most effective for prevention?Answer →
  31. 31A nurse is preparing to reposition a client towards the head of the bed. In which of the following positions should the nurse place the client before repositioning them to the head of the bed?Answer →
  32. 32A nurse is providing discharge teaching to a client recently diagnosed with dry age-related macular degeneration (AMD). Which instruction should the nurse prioritize to help slow the progression of the disease and manage the client's vision loss?Answer →
  33. 33A client presents with a partial-thickness burn covering 20% of their total body surface area (TBSA) after an industrial accident. What is the most appropriate initial action by the nurse to manage fluid resuscitation for this client?Answer →
  34. 34The nurse is planning care for the patient with burns. Which of the following statements indicates the patient understands their nutritional needs?Answer →
  35. 35A client has a stage 3 pressure injury on the coccyx. Which food will be most beneficial in improving the healing process?Answer →
  36. 36The nurse administered an intravenous dose of fentanyl 10 minutes ago to a client with extensive burns. Which finding indicates the client may need an increase in the dose?Answer →
  37. 37When providing wound care for a client with burns, which of the following actions is the most effective strategy to prevent infection?Answer →
  38. 38The initial management of a burn patient includes the assessment of the total body surface area (TBSA) injury, using the rule of nines. The patient was burned on 1/2 of the face, neck, chest above nipple line, top of right arm, mid left arm. What is the purpose of the rule of nines in burn management?Answer →
  39. 39A nurse is caring for a client who is receiving phototherapy for psoriasis. Which of the following findings should the nurse identify as an indication of overexposure?Answer →
  40. 40A nurse is caring for a group of clients. Which of the following clients should the nurse identify is at highest risk for developing a pressure injury?Answer →
  41. 41A nurse is planning care for a client who has a stage 3 pressure ulcer with moderate exudate. The nurse should plan to use which of the following dressings to cover the wound?Answer →
  42. 42A client with fourth degree burns on the left lower leg is brought to the hospital. What clinical finding should the nurse expect to observe?Answer →
  43. 43A nurse is assessing multiple burn patients after a chemical accident. Which patient should the nurse see first based on the severity and potential complications of their burn?Answer →
  44. 44Hours after initial burn fluid resuscitation, the patient's labs are rechecked. Which lab findings would the nurse anticipate due to the second fluid shift? (Select all that apply)Answer →
  45. 45A nurse is orienting a new staff member to the use of pressure-relieving mattresses. Which statement by the new staff member indicates a need for further teaching?Answer →
  46. 46A patient presents with a pressure ulcer that has a full-thickness skin loss but no muscle or bone exposure. Which stage does this pressure ulcer likely represent?Answer →
  47. 47A nurse is assessing a client who has full-thickness burns. The nurse should identify that which of the following findings indicates the client's need for fluid resuscitation?Answer →
  48. 48A client presents to the emergency department with burns covering 20% of their total body surface area. How will the nurse determine that fluid resuscitation in this client has been effective?Answer →
  49. 49When measuring the size, depth, and wound tunneling of a client's stage IV pressure ulcer, what action should the nurse perform first?Answer →
  50. 50A client asks about the 'E' in the ABCDE method skin cancer self-assessment. Which of the following responses by the nurse is accurate?Answer →
  51. 51The nurse manager reviews the electronic health records of several clients with impaired mobility to evaluate the unit's compliance with client repositioning schedules. What assessment finding in the chart indicates effective prevention of skin breakdown?Answer →
  52. 52A client presents with a partial-thickness burn covering 20% of their total body surface area (TBSA) after an industrial accident. For each nursing action, indicate whether it is Anticipated or Contraindicated for managing this client.Answer →
  53. 53The nurse is caring for a client with a pressure ulcer. Which laboratory finding best indicates the client may have poor wound healing?Answer →
  54. 54The nurse admits a client with a non-healing wound and reviews their electronic health record. What finding in the client's chart should the nurse identify as contributing to delayed wound healing?Answer →
  55. 55A nurse is teaching a client who has burns to the upper body about positioning to prevent contractures. Which of the following information should the nurse include?Answer →
  56. 56A nurse assesses an immobile client. Which finding is most consistent with a deep tissue pressure injury?Answer →
  57. 57Which side effects would you monitor for in a patient using a topical cream containing capsaicin and menthol?Answer →
  58. 58A nurse is assisting with teaching a class of newly licensed nurses about the first phase of wound healing. Which of the following processes should the nurse include?Answer →
  59. 59Which of the following represents the most accurate and professional example of objective skin documentation?Answer →
  60. 60A 32-year-old male sustains circumferential deep partial-thickness burns with eschar to both lower legs after a workplace chemical accident. Six hours post-injury, he reports increasing pain unrelieved by opioids, numbness in his toes, and tense, shiny skin that feels firm to palpation. Doppler signals are still present. Which of the following statements regarding burn-related compartment syndrome are correct? (Select all that apply)Answer →
  61. 61The nurse is monitoring fluid and electrolyte levels in the emergent phase of a patient with a burn injury. Which of the following will the nurse anticipate occurring? Select all that applyAnswer →
  62. 62A burn patient had an indwelling urinary catheter Inserted and 1000mLs of red-colored urine was measured from the catheter bag. As the nurse you understand that the patient's red urine is caused by:Answer →
  63. 63A nurse is assessing a patient with a thermal injury and documents the wound as being mottled red and white with ruptured blisters and moderate edema. Which clinical finding best supports this classification?Answer →
  64. 64A nurse is providing an in-service regarding the differences between heat exhaustion and heat stroke. Select the correct clinical manifestations as heat exhaustion, heat stroke, or both:Answer →
  65. 65A nurse is performing a skin assessment for a client who has been on bed rest for 1 week. The nurse notes reddened areas on the client's scapulae. Which Of the following actions should the nurse take?Answer →
  66. 66A nurse is caring for a 70-year-old client who has a pressure injury in the coccyx area. The nurse identifies that which of the following factors associated with aging may impact the ability for the ulcer to heal?Answer →
  67. 67A nurse is collecting data on a client who has impaired mobility. The nurse should monitor the client for a pressure injury due to which of the following factors?Answer →
  68. 68A nurse assesses a client who has been unable to turn independently after pelvic surgery. The nurse notes an open wound on the client's sacrum. The wound has a shallow crater with visible subcutaneous fat, but no muscle, tendon, or bone is exposed. Based on these findings, the nurse should document the wound as a: Select the correct stage.Answer →
  69. 69The wound care clinical nurse specialist has been consulted to evaluate a wound on the leg of a client with diabetes. The wound care nurse determines that damage has occurred to the full thickness of the subcutaneous tissues. How would she document this wound?Answer →
  70. 70A patient has a burn covering the anterior torso and both legs. Based on the Rule of Nines, what is the total percentage of Total Body Surface Area (TBSA) affected?Answer →
  71. 71A nurse is providing discharge teaching to a client following an excisional biopsy of a skin lesion. Which of the following information should the nurse include in the teaching?Answer →
  72. 72A nurse is caring for a client who has a wound infection. Which of the following actions should the nurse take when obtaining a wound drainage specimen for culture?Answer →
  73. 73During the nurse's initial assessment, which finding is most concerning and requires immediate attention?Answer →
  74. 74A male nurse is assigned to care for a female client who was admitted to the hospital for treatment of injuries following a domestic abuse incident. The client tells the nurse manager she does not want a male nurse as her caregiver. Which of the following nursing responses should the nurse manager make?Answer →
  75. 75The nurse is assessing a client's skin. They note a lesion on the left anterior upper arm. What characteristics if noted would raise the concern for skin cancer?Answer →
  76. 76A nurse is assessing a client with long-standing diabetes who has black, dry, well-demarcated tissue on two toes. The client reports minimal pain. Which action should the nurse take first?Answer →
  77. 77A nurse assesses a client who has been unable to turn independently after pelvic surgery. The nurse notes an open wound on the client's sacrum. The wound has a shallow crater with visible subcutaneous fat, but no muscle, tendon, or bone is exposed. Based on these findings, the nurse should document the wound as a: Select the correct stage.Answer →
  78. 78A nurse is caring for a client who has a wound infection. Which of the following actions should the nurse take when obtaining a wound-drainage specimen for culture?Answer →
  79. 79Priority intervention for intertrigo in skin folds?Answer →
  80. 80A surgical incision that is healing by secondary intention develops a thick tan exudate. Which action should the nurse take first?Answer →
  81. 81A client presents to the emergency department following a chemical burn from an industrial solvent. What is the nurse's priority intervention?Answer →
  82. 82When caring for four clients, which does the nurse identify as at the highest risk for frostbite?Answer →
  83. 83An older adult client comes to the clinic with a productive cough that has been troublesome for the past two weeks. The nurse observes long ecchymotic marks on the client's trunk. When measured with a disposable ruler, they are 2.54 cm (1 inch) in diameter. Which action should the nurse implement?Answer →
  84. 84Self-administration of topical clindamycin (Cleocin) is being performed properly if the patient does what?Answer →
  85. 85Which of the following is a viral skin infection?Answer →
  86. 86A nurse is caring for a hospitalized patient who has severe facial burns and signs of increasing laryngeal edema. Which intervention is most appropriate to anticipate and advocate for to prevent total airway obstruction?Answer →
  87. 87A nurse is performing a skin assessment on a patient with multiple nevi (moles). Which finding should the nurse identify as a "red flag" requiring further evaluation for potential melanoma?Answer →
  88. 88A client presents to the urgent care center with a knife wound to the left hand. What line of defense does the nurse recognize as being initiated within seconds of the client's injuries?Answer →
  89. 89A nurse is caring for a client with a wound. Which of the following cultural considerations should the nurse consider when making the plan of care?Answer →
  90. 90A nurse receives a patient with burns covering the entire left arm and the front of the trunk. Using the Rule of Nines, what percentage of Total Body Surface Area (TBSA) is affected?Answer →
  91. 91A nurse is assessing a client who has a stage 3 pressure injury. Which of the following findings indicates possible infection of the wound?Answer →
  92. 92A client visits the clinic and is diagnosed with seborrheic dermatitis. The health care provider prescribes treatment. Which should the nurse anticipate giving to the client for treatment?Answer →
  93. 93A nurse is assisting with teaching a newly licensed nurse about massage therapy. The nurse should include that a massage is contraindicated for clients who have which of the following conditions?Answer →
  94. 94A nurse working in long-term care is assessing residents at risk for the development of a pressure injury. Which one would be most at risk?Answer →
  95. 95Which action is most important to prevent skin breakdown in an immobile patient?Answer →
  96. 96A 68-year-old patient is found outside on a cold winter day and brought to the ED. Core temperature is 88°F (31°C). The patient is drowsy, shivering, and is breathing 12 breaths/minute. Which of the following actions should the nurse implement first to begin rewarming the patient?Answer →
  97. 97A nurse is evaluating a patient with cellulitis of the left forearm. Which new finding is most concerning?Answer →
  98. 98The nurse is preparing to care for a patient with a burn to the arm that the patient is unable to flex. The patient is scheduled for an escharotomy procedure being performed for a third-degree circumferential arm burn. The nurse understands that which finding is the anticipated therapeutic outcome of the escharotomy?Answer →
  99. 99A nurse assesses an immobile client. Which finding is most consistent with a deep tissue pressure injury?Answer →
  100. 100A nurse is assessing a patient's skin for signs of malignant melanoma. Which of the following characteristics would be most concerning?Answer →
  101. 101A 25-year-old male presents to the burn unit after accidentally spilling hot coffee on his forearm. On examination, the affected area is red with blisters, mild to moderate edema, and very painful. The patient asks how long it will take to heal and whether he will have permanent scarring. Which type of burn does this most likely represent, and what is the expected healing outcome?Answer →