NCLEX-PN
Integumentary Disorders NCLEX Questions Questions
Question 1 of 5
The client comes into the emergency department in severe pain and reports that a pot of boiling hot water accidentally spilled on his lower legs. The assessment reveals blistered, mottled red skin, and both feet are edematous. Which depth of burn should the nurse document?
Correct Answer: B
Rationale: Blistered, mottled red skin with edema indicates deep partial-thickness burns, affecting the dermis with severe pain. Superficial partial thickness has no blisters, full thickness is painless and leathery, and first degree is superficial with erythema.
Question 2 of 5
The nurse writes the nursing diagnosis 'impaired skin integrity related to open burn wounds.' Which intervention would be appropriate for this nursing diagnosis?
Correct Answer: B
Rationale: Daily wound cleaning prevents infection and promotes healing, addressing impaired skin integrity. Analgesia addresses pain, visitor screening is for infection control, and plants increase infection risk.
Question 3 of 5
The nurse in a long-term care facility is teaching a group of new unlicensed assistive personnel. Which information regarding skin care should the nurse emphasize?
Correct Answer: C
Rationale: Turning every 2 hours prevents pressure ulcers by relieving pressure. Damp skin risks breakdown, lotion is beneficial, and UAPs can assist with skin care.
Question 4 of 5
The nurse and an unlicensed assistive personnel (UAP) on a medical floor are caring for clients who are elderly and immobile. Which action by the UAP warrants immediate intervention by the nurse?
Correct Answer: B
Rationale: Delaying turning immobile clients risks pressure ulcers, requiring immediate intervention. Bed elevation, restocking, and Thick-It are appropriate.
Question 5 of 5
The school nurse is preparing to teach a health promotion class to high school seniors. Which information regarding self-care should be included in the teaching?
Correct Answer: C
Rationale: Monthly skin checks detect early skin cancer changes. SPF 10 is inadequate, 0300–0500 is nighttime, and caps/long sleeves are protective.