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

Assessing for rhinorrhea or otorrhea

Monitoring for changes in the client's baseline focused assessment

Documenting the relevant information in the client's medical record

Range of motion (ROM) of the restrained extremity

Answer and Explanation

The Correct Answer is B

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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Correct Answer is B

Explanation

A. Circular, erythematous patches on the scalp:
Describes tinea capitis, not tinea pedis.

B. Scaling and redness between the toes:
Classic symptoms of tinea pedis (athlete’s foot), a fungal infection often affecting the web spaces of toes.

C. Recent exposure to poison ivy:
Suggests allergic contact dermatitis, not fungal infection.

D. A recent prescription for an antiseizure medication:
More suggestive of Stevens-Johnson syndrome or drug reactions-not tinea pedis.

A. Bright-red, moist lesions B. Blackened, painful lesions C. Snowy white, painless lesions D. Blistered, pinkish-white, painful lesions

Correct Answer is C

Explanation

A. Bright-red, moist lesions:
This describes superficial partial-thickness burns, not full-thickness burns.

B. Blackened, painful lesions:
Full-thickness burns may appear black (eschar), but they are typically painless due to nerve destruction.

C. Snowy white, painless lesions:
Full-thickness burns can be white, leathery, or charred and are often painless due to complete nerve damage.

D. Blistered, pinkish-white, painful lesions:
These are characteristic of deep partial-thickness burns, which retain some nerve sensation.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in a provider's office is caring for a client who has tinea pedis. Which of the following findings should the nurse expect?

Correct Answer is B

Explanation

A patient is brought to the emergency department after a house fire. the patient has extensive trunk and lower extremity burns and is diagnosed with a full thickness burn. What assessment findings does the nurse expect?

Correct Answer is C

Explanation

When prioritizing the care of a client with burns, which intervention should the nurse implement first?

A nurse is caring for a client who has burns to his face, ears, and eyelids. Which of the following is the priority finding to report to the provider?

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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?

A nurse is discussing pressure ulcer staging with a newly licensed nurse. Which of the following statements should the nurse use to describe a stage 3 pressure ulcer?

A patient is to receive heparin 6,000 units subcutaneously every 12 hours for DVT. The pharmacy dispenses a vial containing 10,000 units/1 mL. How many milliliters of heparin should the nurse administer? Express to the tenth.