A nurse is assessing a patient who presents with a scaly, crusted lesion with a central ulceration on the lower leg, as shown in the image. The lesion appears rough, firm, and does not heal despite previous treatments. The nurse suspects squamous cell carcinoma (SCC). What is the priority nursing action?

Apply an antibiotic ointment and reassess in two weeks.

Refer the patient to a dermatologist for a biopsy.

Reassure the patient that the lesion is benign and monitor for changes.

Educate the patient on proper wound care and sun protection.

Answer and Explanation

The Correct Answer is B

A. Apply an antibiotic ointment and reassess in two weeks. SCC is a form of skin cancer and requires biopsy for diagnosis. Simply applying an antibiotic and waiting could delay necessary treatment.

B. Refer the patient to a dermatologist for a biopsy. The priority action for a suspicious lesion that does not heal is to refer the patient for biopsy and further evaluation, as early detection and treatment of SCC are crucial.

C. Reassure the patient that the lesion is benign and monitor for changes. SCC can be aggressive if untreated, and assuming benignity without biopsy could result in delayed diagnosis and worsening prognosis.

D. Educate the patient on proper wound care and sun protection. While wound care and sun protection are important, the priority is obtaining a definitive diagnosis through biopsy.

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Correct Answer is B

Explanation

A. Weigh the patient daily to monitor fluid balance. Daily weights are useful for tracking fluid shifts but are not the priority in the acute phase of burn management.

B. Monitor urine output to ensure at least 30 mL/hr. Urine output is a key indicator of adequate fluid resuscitation. A minimum of 30 mL/hr ensures proper kidney perfusion and prevents hypovolemia or fluid overload.

C. Assess for signs of fluid deficit such as lung crackles and engorged neck veins. Crackles and neck vein distension indicate fluid overload, not deficit. While monitoring for overload is important, urine output is the best immediate indicator of effective fluid resuscitation.

D. Administer only colloid solutions within the first 8 hours post-burn. Crystalloids (e.g., Lactated Ringer’s) are the primary fluids used in the first 24 hours post-burn. Colloids are typically introduced later.

A. “I will keep my cast dry and avoid inserting objects inside to scratch my skin." B. "If I notice increased swelling, numbness, or severe pain, I will elevate my leg and notify my provider immediately." C. "It's okay to use a blow dryer on a cool setting to help dry my cast if it gets wet." D. “I should expect to feel extreme pain under the cast that doesn't improve with pain medication."

Correct Answer is D

Explanation

A. “I will keep my cast dry and avoid inserting objects inside to scratch my skin.” Keeping the cast dry prevents it from softening or breaking down, which could lead to improper healing. Avoiding objects inside the cast prevents skin injuries and infections.

B. "If I notice increased swelling, numbness, or severe pain, I will elevate my leg and notify my provider immediately." Increased swelling, numbness, and severe pain can indicate compartment syndrome or impaired circulation. Elevating the leg and seeking medical attention is appropriate.

C. "It's okay to use a blow dryer on a cool setting to help dry my cast if it gets wet." A blow dryer on a cool setting can be used to help dry moisture inside the cast without causing burns or affecting the cast material.

D. “I should expect to feel extreme pain under the cast that doesn't improve with pain medication.” Extreme pain that is unrelieved by medication is abnormal and may indicate complications like compartment syndrome, infection, or pressure ulcers under the cast. The patient needs further education that severe pain should be reported immediately.

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a patient with 40% TBSA burns who is receiving fluid resuscitation. Which of the following nursing interventions is the priority?

Correct Answer is B

Explanation

The nurse is evaluating a patient's understanding of cast care before discharge. Which statement by the patient indicates the need for further teaching?

Correct Answer is D

Explanation

Which of the following actions should the nurse take immediately to prevent complications?

A nurse is reviewing the medical record of a patient diagnosed with Stevens-Johnson Syndrome (SJS). Which of the following findings should the nurse identify as the most likely cause of this condition?

A nurse is caring for a client who has a new short-leg cast on his lower leg to treat an ankle fracture. Which of the following findings requires immediate notification of the provider?

A nurse is providing medication education to a patient newly prescribed ethambutol for tuberculosis (TB) treatment. The nurse should instruct the patient to report which of the following side effects immediately?

A nurse in an emergency department is caring for a client who has deep partial- and full-thickness burns to his chest, abdomen, and upper arms. What is the nurse's priority intervention for this client during the resuscitation phase of injury?

A nurse is assessing a client who has a fracture of the femur. The nurse obtains vital signs on admission and again in 2 hours. Which of the following changes in assessment should indicate to the nurse that the client could be developing a serious complication?

A nurse is assessing a bedridden patient and notes a reddened area on the sacrum that does not blanch when pressed. The skin is intact. Based on this finding, which stage of pressure ulcer should the nurse document?

A nurse is assessing a patient who sustained partial-thickness burns to the anterior chest and anterior left arm. Using the Rule of Nines, what percentage of total body surface area (TBSA) is affected?