NCLEX-RN
Integumentary Disorders NCLEX RN Questions Questions
Question 1 of 5
The nurse is conducting a staff in-service on managing an acute burn. The nurse should reinforce the utilization of which formula to guide fluid resuscitation?
Correct Answer: A
Rationale: The Parkland formula (4 mL x kg x TBSA burned) is used to calculate fluid resuscitation needs in burn patients to restore circulating volume.
Question 2 of 5
Which of the following interventions by the newly hired nurse requires follow-up? Select all that apply.
Correct Answer: B, C
Rationale: Donut pillows can increase pressure on surrounding tissues, worsening ulcer risk. Maintaining the head of the bed at 90 degrees increases shearing forces, promoting ulcer development. Zinc oxide, high-protein diets (not just carbohydrates), and floating heels are appropriate interventions.
Question 3 of 5
Which of the following accurately summarizes the primary purpose of skin care and hygiene?
Correct Answer: C
Rationale: The skin is the body's first line of defense against pathogens and injury, and proper skin care maintains its integrity.
Question 4 of 5
A nurse is caring for a client at risk of developing pressure ulcers. Which of the following is an intrinsic risk factor that contributes to this increased risk?
Correct Answer: C
Rationale: Impaired tissue perfusion is an intrinsic risk factor because it originates within the body, affecting blood flow and tissue oxygenation, which can lead to pressure ulcer development. Shearing, friction, and pressure are extrinsic factors as they are external forces acting on the skin.
Extract:
The nurse cares for a 29-year-old male in the emergency department (ED)
Item 5 of 6
Nurses' Note
Vital Signs
Assessment
2115: Client brought by emergency medical services (EMS) for a thermal burn injury while setting up a fire outside. His right arm caught fire as some of the lighter fluid he used was on his sweater. The fire then spread to his back and part of his chest. The client has sustained full- thickness burns to his right hand and entire arm. Deep partial thickness burns were observed to his right torso and entire back. The client arrives screaming in pain rating it as 9 on a scale of 0 (no pain) to 10 (severe pain). He endorses no pain in his right arm or hand, stating it feels 'numb.' EMS started a 16-gauge peripheral vascular access device in the left antecubital space.
Question 5 of 5
The nurse should plan to obtain a prescription for ………………….. to restore circulating volume. The ……………………… will be used to determine the 24-hour fluid requirement. To measure the effectiveness of the fluid replacement, the nurse plans to …………………………..
Correct Answer: C, D, G
Rationale: Lactated Ringers restores circulating volume, the Parkland formula calculates fluid needs, and a urinary catheter monitors output to assess fluid replacement effectiveness.