A nurse is reinforcing teaching with a client about maintaining skin integrity to decrease the risk of infection. Which of the following instructions should the nurse include?

"Use a moisturizer on your skin after cleaning."

"Rub your skin firmly when cleaning."

"Wash your skin daily with hot water.”

"Allow your skin to air dry after bathing.”

Answer and Explanation

The Correct Answer is A

A. "Use a moisturizer on your skin after cleaning."
Moisturizers help maintain skin hydration and barrier function, reducing the risk of breakdown and infection.

B. "Rub your skin firmly when cleaning."
This can cause microabrasions and increase the risk of skin breakdown and infection.

C. "Wash your skin daily with hot water.”
Hot water can dry out the skin and compromise the skin barrier, increasing infection risk.

D. "Allow your skin to air dry after bathing.”
Patting the skin dry is better than air drying, which can lead to excessive dryness and irritation.

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Correct Answer is B

Explanation

A. Percent of body surface burned:
Important for guiding fluid resuscitation, but airway and breathing always take priority in the ABCs.

B. Respiratory status:
Inhalation injury is a life-threatening complication in fire-related burns. Assess for stridor, soot in nares/mouth, and signs of respiratory distress first.

C. Review of chronic illnesses:
Relevant for overall care planning, but not an initial priority in the emergency phase.

D. Burn depth:
Guides long-term care but is secondary to airway and breathing in the acute setting.

A. Assessing for rhinorrhea or otorrhea B. Monitoring for changes in the client's baseline focused assessment C. Documenting the relevant information in the client's medical record D. Range of motion (ROM) of the restrained extremity

Correct Answer is B

Explanation

A. Assessing for rhinorrhea or otorrhea:
Relevant in head trauma or skull fracture, not a priority in impaired mobility related to burns.

B. Monitoring for changes in the client's baseline focused assessment:
Changes in perfusion, sensation, and mobility may indicate compartment syndrome or pressure injuries and need prompt attention.

C. Documenting the relevant information in the client's medical record:
Important for continuity of care, but not the priority assessment.

D. Range of motion (ROM) of the restrained extremity:
Helpful to prevent contractures, but monitoring for clinical deterioration takes precedence.

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A nurse is reinforcing teaching with a client about maintaining skin integrity to decrease the risk of infection. Which of the following instructions should the nurse include?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client is brought to the emergency department with burns over 40% of the body from apartment fire. Which assessment should take priority?

Correct Answer is B

Explanation

Which of the following assessments should the nurse prioritize for a burn patient with impaired physical mobility?

Correct Answer is B

Explanation

A nurse is inspecting a lesion on a client who has basal cell carcinoma. Which of the following findings should the nurse expect?

The nurse is caring for a patient with lesions on the skin. Which of the following assessment findings would cause the nurse to suspect scabies?

A nurse is collecting data from four clients who have wounds. The nurse should recognize that which of the following clients has a manifestation of a wound infection?

A nurse is caring for a client with severe burns to both lower extremities. The client is scheduled for an escharotomy and wants to know what the procedure involves. Which of the following statements is appropriate for the nurse to make?

A nurse at a community center is assisting with a presentation about sun protection to a group of residents. Which of the following responses by the residents indicates an understanding of the teaching?

A nurse is caring for an older adult client who is at risk for skin breakdown. Which of the following interventions should the nurse use to help maintain the client's skin integrity?

A nurse is assisting in the care of a client who has severe burns. Exhibits Which of the following actions should the nurse take when caring for a client who has severe burns to the lower extremities? Select all that apply.