Question 1 See full question

When assessing a client who is incontinent for risk for developing a pressure ulcer, the nurse

should note which factor that can most alter tissue tolerance and lead to the development of a

pressure ulcer?

You Selected:

• exposure to moisture

Correct response:

• exposure to moisture

 Explanation:

 Remediation:

Question 2 See full question

The nurse is assessing a hospitalized older client for the presence of pressure ulcers. The nurse

notes that the client has a 1 inch × 1 inch (3 cm x 3 cm) area on the sacrum in which there is

skin breakdown as far as the dermis. What should the nurse note on the medical record?

You Selected:

• stage I pressure ulcer

Correct response:

• stage II pressure ulcer

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 Explanation:

 Remediation:

Question 3 See full question

Which factor is most important for the nurse to consider when determining the angle at which

to insert the needle for a subcutaneous injection?

You Selected:

• length of the needle

Correct response:

• amount of subcutaneous tissue

 Explanation:

 Remediation:

Question 4 See full question

During the first 48 to 72 hours of fluid resuscitation therapy after a major burn injury, the nurse

should monitor hourly which information that will be used to determine the IV infusion rate?

You Selected:

• urine output

Correct response:

• urine output

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 Explanation:

 Remediation:

Question 5 See full question

A nurse is preparing a discharge teaching plan for a client with atopic dermatitis. Which

instruction should the nurse include in her teaching plan?

You Selected:

• Use a topical skin moisturizer daily.

Correct response:

• Use a topical skin moisturizer daily.

 Explanation:

 Remediation:

Question 6 See full question

A client with deep partial-thickness and full-thickness burns on the arms receives autografts.

Two days later, the nurse finds the client doing arm exercises. The nurse provides additional

client teaching because these exercises may:

You Selected:

• dislodge the autografts.

Correct response:

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• dislodge the autografts.

 Explanation:

 Remediation:

Question 7 See full question

A client has partial-thickness burns on both lower extremities and portions of the trunk. Which

I.V. fluid does the nurse plan to administer first?

You Selected:

• Lactated Ringer's solution

Correct response:

• Lactated Ringer's solution

 Explanation:

 Remediation:

Question 8 See full question

The nurse is caring for an immune compromised client with a fungal infection of the scalp.

What recommendation should the nurse make to prevent future problems?

You Selected:

• Wash hair with a dandruff-preventing shampoo.

Correct response:

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