1. When planning care for a male client with burns on the upper torso, which nursing diagnosis should take the highest priority?
a. Ineffective airway clearance related to edema of the respiratory passages
b. Impaired physical mobility related to the disease process
c. Disturbed sleep pattern related to facility environment
d. Risk for infection related to breaks in the skin
2. In a female client with burns on the legs, which nursing intervention helps prevent contractures?
a. Applying knee splints
b. Elevating the foot of the bed
c. Hyperextending the client’s palms
d. Performing shoulder range-of-motion exercises
3. A male client comes to the physician’s office for treatment of severe sunburn. The nurse takes this opportunity to discuss the importance of protecting the skin from the sun’s damaging rays. Which instruction would best prevent skin damage?
a. “Minimize sun exposure from 1 to 4 p.m. when the sun is strongest.”
b. “Use a sunscreen with a sun protection factor of 6 or higher.”
c. “Apply sunscreen even on overcast days.”
d. “When at the beach, sit in the shade to prevent sunburn.”
4. A female client is brought to the emergency department with second- and third-degree burns on the left arm, left anterior leg, and anterior trunk. Using the Rule of Nines, what is the total body surface area that has been burned?
5. Which nursing intervention can help a client maintain healthy skin?
a. Keep the client well hydrated.
b. Avoid bathing the client with mild soap.
c. Remove adhesive tape quickly from the skin.
d. Recommend wearing tight-fitting clothes in hot weather.
6. A male client with psoriasis visits the dermatology clinic. When inspecting the affected areas, the nurse expects to see which type of secondary lesion?
7. A female adult client with atopic dermatitis is prescribed a potent topical corticosteroid, to be covered with an occlusive dressing. To address a potential client problem associated with this treatment, the nurse formulates the nursing diagnosis of Risk for injury. To complete the nursing diagnosis statement, the nurse should add which “related-to” phrase?
a. Related to potential interactions between the topical corticosteroid and other prescribed drugs
b. Related to vasodilatory effects of the topical corticosteroid
c. Related to percutaneous absorption of the topical corticosteroid
d. Related to topical corticosteroid application to the face, neck, and intertriginous sites
8. A male client is diagnosed with herpes simplex. Which statement about herpes simplex infection is true?
a. During early pregnancy, herpes simplex infection may cause spontaneous abortion or premature delivery.
b. Genital herpes simplex lesions are painless, fluid-filled vesicles that ulcerate and heal in 3 to 7 days
c. Herpetic keratoconjunctivitis usually is bilateral and causes systemic symptoms.
d. A client with genital herpes lesions can have sexual contact but must use a condom.
9. A female client with a severe staphylococcal infection is receiving the aminoglycoside gentamicin sulfate (Garamycin) by the I.V. route. The nurse should assess the client for which adverse reaction to this drug?
a. Aplastic anemia
c. Cardiac arrhythmias
10. A male client is diagnosed with primary herpes genitalis. Which instruction should the nurse provide?
a. “Apply one applicator of terconazole intravaginally at bedtime for 7 days.”
b. “Apply one applicator of tioconazole intravaginally at bedtime for 7 days.”
c. “Apply acyclovir ointment to the lesions every 3 hours, six times a day for 7 days.”
d. “Apply sulconazole nitrate twice daily by massaging it gently into the lesions.”
11. Nurse Bea plans to administer dexamethasone cream to a client who has dermatitis over the anterior chest How should the nurse apply this topical agent?
a. With a circular motion, to enhance absorption
b. With an upward motion, to increase blood supply to the affected area
c. In long, even, outward, and downward strokes in the direction of hair growth
d. In long, even, outward, and upward strokes in the direction opposite hair growth
12. Nurse Meredith is caring for a wheelchair-bound client. Which piece of equipment impedes circulation to the area it’s meant to protect?
a. Polyurethane foam mattress
b. Ring or donut
c. Gel flotation pad
d. Water bed
13. Nurse Rudolf documents the presence of a scab on a client’s deep wound. The nurse identifies this as which phase of wound healing?
14. In an industrial accident, a male client that weighs 155 lb (70 kg) sustained full-thickness burns over 40% of his body. He’s in the burn unit receiving fluid resuscitation. Which observation shows that the fluid resuscitation is benefiting the client?
a. A urine output consistently above 100 ml/hour
b. A weight gain of 4 lb (2 kg) in 24 hours
c. Body temperature readings all within normal limits
d. An electrocardiogram (ECG) showing no arrhythmias
15. A female client with herpes zoster is prescribed acyclovir (Zovirax), 200 mg P.O. every 4 hours while awake. The nurse should inform the client that this drug may cause:
d. metallic taste.
16. A female client sees a dermatologist for a skin problem. Later, the nurse reviews the client’s chart and notes that the chief complaint was intertrigo. This term refers to which condition?
a. Spontaneously occurring wheals
b. A fungus that enters the skin’s surface, causing infection
c. Inflammation of a hair follicle
d. Irritation of opposing skin surfaces caused by friction
17. A male client who has suffered a cerebrovascular accident (CVA) is too weak to move on his own. To help the client avoid pressure ulcers, the nurse should:
a. turn him frequently.
b. perform passive range-of-motion (ROM) exercises.
c. reduce the client’s fluid intake.
d. encourage the client to use a footboard.
18. A male client visits the physician’s office for treatment of a skin disorder. As a primary treatment, the nurse expects the physician to prescribe:
a. an I.V. corticosteroid.
b. an I.V. antibiotic.
c. an oral antibiotic.
d. a topical agent.
19. While in a skilled nursing facility, a male client contracted scabies, which is diagnosed the day after discharge. The client is living at her daughter’s home, where six other persons are living. During her visit to the clinic, she asks a staff nurse, “What should my family do?” The most accurate response from the nurse is:
a. “All family members will need to be treated.”
b. “If someone develops symptoms, tell him to see a physician right away.”
c. “Just be careful not to share linens and towels with family members.”
d. “After you’re treated, family members won’t be at risk for contracting scabies.”
20. When caring for a male client with severe impetigo, the nurse should include which intervention in the plan of care?
a. Placing mitts on the client’s hands
b. Administering systemic antibiotics as prescribed
c. Applying topical antibiotics as prescribed
d. Continuing to administer antibiotics for 21 days as prescribed
21. A female client with second- and third-degree burns on the arms receives autografts. Two days later, the nurse finds the client doing arm exercises. The nurse knows that this client should avoid exercise because it may:
a. dislodge the autografts.
b. increase edema in the arms.
c. increase the amount of scarring.
d. decrease circulation to the fingers.
22. Nurse Troy discovers scabies when assessing a client who has just been transferred to the medical-surgical unit from the day surgery unit. To prevent scabies infection in other clients, the nurse should:
a. wash hands, apply a pediculicide to the client’s scalp, and remove any observable mites.
b. isolate the client’s bed linens until the client is no longer infectious.
c. notify the nurse in the day surgery unit of a potential scabies outbreak.
d. place the client on enteric precautions.
23. Dr. Smith prescribes an emollient for a client with pruritus of recent onset. The client asks why the emollient should be applied immediately after a bath or shower. How should the nurse respond?
a. “This makes the skin feel soft.”
b. “This prevents evaporation of water from the hydrated epidermis.”
c. “This minimizes cracking of the dermis.”
d. “This prevents inflammation of the skin.”
24. Following a full-thickness (third-degree) burn of his left arm, a female client is treated with artificial skin. The client understands postoperative care of artificial skin when he states that during the first 7 days after the procedure, he will restrict:
a. range of motion.
b. protein intake.
c. going outdoors.
d. fluid ingestion.
25. A male client with a solar burn of the chest, back, face, and arms is seen in urgent care. The nurse’s primary concern should be:
a. fluid resuscitation.
c. body image.
d. pain management.
26. The nurse is providing home care instructions to a client who has recently had a skin graft. It’s most important that the client remember to:
a. use cosmetic camouflage techniques.
b. protect the graft from direct sunlight.
c. continue physical therapy.
d. apply lubricating lotion to the graft site.
27. A male client is diagnosed with gonorrhea. When teaching the client about this disease, the nurse should include which instruction?
a. “Avoid sexual intercourse until you’ve completed treatment, which takes 14 to 21 days.”
b. “Wash your hands thoroughly to avoid transferring the infection to your eyes.”
c. “If you have intercourse before treatment ends, tell sexual partners of your status and have them wash well after intercourse.”
d. “If you don’t get treatment, you may develop meningitis and suffer widespread central nervous system (CNS) damage.”
28. A female client with atopic dermatitis is prescribed medication for photochemotherapy. The nurse teaches the client about the importance of protecting the skin from ultraviolet light before drug administration and for 8 hours afterward and stresses the need to protect the eyes. After administering medication for photochemotherapy, the client must protect the eyes for:
a. 4 hours.
b. 8 hours.
c. 24 hours.
d. 48 hours.
29. A female client with genital herpes simplex is being treated in the outpatient department. The nurse teaches her about measures that may prevent herpes recurrences and emphasizes the need for prompt treatment if complications arise. Genital herpes simplex increases the risk of:
a. cancer of the ovaries.
b. cancer of the uterus.
c. cancer of the cervix.
d. cancer of the vagina.
30. Which of the following is the initial intervention for a male client with external bleeding?
a. Elevation of the extremity
b. Pressure point control
c. Direct pressure
d. Application of a tourniquet
How to Pass the NCLEX