NCLEX-RN
Integumentary NCLEX RN Questions Questions
Extract:
The emergency department (ED) nurse is caring for a client who sustained a witnessed electrical burn
Item 1 of 1
Triage Note
Triage Vital Signs
1730: A 35-year-old male was brought to the emergency department (ED) by his father after they were working on electrical wiring at a residential house. The client's father witnessed his son grab a wire and sustain a significant 'jolt' for five to ten seconds. The client briefly lost consciousness and was disoriented immediately afterward. The client was immediately placed in the father's car and transported to the ED. A localized burn was noted on the client's right hand. Scant sanguineous drainage noted. The client reports pain of a '6' (0= no pain; 10= severe pain) that is worsened with movement. The client is alert and oriented to place and time; however, he does not recall the situation that brought him to the hospital. Glasgow
Coma Scale (GCS) 14. The client reports that he feels like his 'heart is intermittently skipping.'
Question 1 of 5
The nurse is immediately concerned that the client is at risk for developing …………….. as evidenced by the client's ………………
Correct Answer: C, E
Rationale: The client's report of feeling like his 'heart is intermittently skipping' indicates a potential cardiac dysrhythmia, which is a serious complication of electrical burns due to the effect of electrical current on the heart. The pulse is the finding that supports this concern.
Extract:
Question 2 of 5
A nurse is taking care of a client with severe burns. Which of the following is the best intervention to prevent shock in this client?
Correct Answer: C
Rationale: Infusing IV fluids is the best intervention to prevent hypovolemic shock in burn patients by restoring circulating volume lost due to fluid shifts from severe burns.
Question 3 of 5
The ABCDEs of melanoma identification include which of the following? Select all that apply.
Correct Answer: A, C, D, E
Rationale: The ABCDEs of melanoma are Asymmetry, Border (irregular), Color (varied), Diameter (>6 mm), and Evolving (changes in appearance or symptoms). Birthmark is not part of this mnemonic.
Question 4 of 5
The nurse is conducting a community health class on skin changes for older adults. It would be appropriate for the nurse to state which of the following are normal age-related changes? Select all that apply.
Correct Answer: A, B, C, D
Rationale: Normal age-related skin changes include decreased dermal blood flow, actinic lentigo (age spots), degeneration of elastic fibers (leading to wrinkles), and loss of subcutaneous fat (thinner skin). Increased epidermal thickness is not typical; the epidermis thins with age.
Question 5 of 5
The nurse is caring for a client with several severe pressure ulcers. Which laboratory result requires the nurse to intervene?
Correct Answer: A
Rationale: A low serum albumin level (2.5 g/dL) indicates malnutrition, which impairs wound healing and requires intervention. Other lab values are within normal ranges.