NCLEX Review about Skin and Integumentary Disorders (46-50)

NCLEX Review about Skin and Integumentary Disorders

46. A community health nurse is providing a teaching session to firefighters in a small community regarding care of a burn victim at the scene of injury. The nurse instructs the firefighters that in the event of a tar burn, the immediate action should be:

a) cooling the injury with water
b) removing all clothing immediately
c) removing the tar from the burn injury
d) leaving any clothing that is saturated with tar in place

47. An industrial nurse is providing instructions to a group of employees regarding care to a client in the event of a chemical burn injury. The nurse instructs the employees that the first consideration in immediate care is:

a) leaving all clothing in place until the client is brought to the emergency department
b) removing all clothing including gloves and shoes
c) lavaging the skin with water and avoiding brushing powdered chemicals off the clothing to prevent further spread of the injury
d) determining the antidote for the chemical and placing the antidote on the burn site



48. A client who sustained an inhalation injury arrives in the emergency department. On initial assessment, the nurse notes that the client is very confused and combative. The nurse determines that the client is experiencing:

a) anxiety
b) fear
c) hypoxia
d) pain

49. A client is brought to the emergency department immediately after a smoke inhalation injury. The initial nursing action should be to prepare the client to receive:

a) pain medication
b) oxygen vial nasal cannula
c) 100% humidified oxygen by face mask
d) endotracheal intubation

50. An emergency department nurse is caring for a client who sustained a burn injury to the anterior arms and anterior chest area from a home fire that originated in the basement. Which of the following assessment findings would indicate that the client sustained a respiratory injury as a result of the burn?

a) clear breath sounds
b) use of accessory muscles for breathing
c) fear and anxiety
d) complaints of pain




NCLEX Review about Skin and Integumentary Disorder:
ANSWERS AND RATIONALE

46) A

- Scald burns and tar or asphalt burns are treated by immediate cooling with water if available, or immediate removal of the saturated clothing. Clothing that is burned into the skin is not removed because increased tissue damage and bleeding may result. No attempt is made to remove tar from the skin at the scene.

47) B

- In a chemical burn injury, the burning process continues so long as the chemical is in contact with the skin. All clothing including gloves and shoes is removed immediately, and water lavage is instituted before and during the transport to the emergency department. Powdered chemicals are first brushed from the clothing and also the skin before lavage is performed.

48) C

- After a burn injury, clients normally are alert. If a client becomes confused or combative, hypoxia may be the cause. Hypoxia occurs after inhalation injury and also may occur after an electrical injury.

49) C

- With a smoke inhalation injury, the client is immediately treated with 100% humidified oxygen delivered by face mask. Endotracheal intubation is needed if the client exhibits respiratory stridor, which indicates airway obstruction. Pain medication may be needed but would not be the initial intervention.

50) B

- Clinical indicators of respiratory injury in a burn-injured client include the presence of facial burns, the presence of soot around the mouth or nose, and singed nasal hairs. Signs of respiratory difficulty include changes in respiratory rate and the use of accessory muscles for breathing. Although anxiety may be a sign of hypoxemia, anxiety along with bradycardia, arrhythmias, and lethargy would be more likely to indicate a concern related to a respiratory injury. Abnormal breath sounds and abnormal arterial blood gas values also would be noted.


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