NCLEX-PN
Integumentary System NCLEX Questions Questions
Question 1 of 5
The client has full-thickness burns to 65% of the body, including the chest area. After establishing a patent airway, which collaborative intervention is priority for the client?
Correct Answer: A
Rationale: Massive fluid loss in 65% burns requires immediate fluid and electrolyte replacement to prevent shock. Contracture prevention, urine monitoring, and escharotomy are secondary after fluid resuscitation.
Question 2 of 5
The nurse is caring for a client with deep partial-thickness and full-thickness burns to the chest area. Which assessment data would warrant notifying the health-care provider?
Correct Answer: C
Rationale: Fever, tachycardia, and hypotension suggest sepsis or hypovolemia, requiring immediate HCP notification. Pain is expected, 95% SpO2 is acceptable, and low urine output is secondary.
Question 3 of 5
The nurse is caring for clients in a long-term care facility. Which is a modifiable risk factor for the development of pressure ulcers?
Correct Answer: A
Rationale: Perineal moisture is modifiable through hygiene and barriers, reducing ulcer risk. Repositioning ability, skin elasticity, and perfusion are less modifiable.
Question 4 of 5
The nurse is developing a plan of care for a client diagnosed with left-sided paralysis secondary to a right-sided cerebrovascular accident (stroke). Which should be included in the interventions?
Correct Answer: A
Rationale: Heel elevation prevents pressure ulcers in paralyzed clients. Low air-loss beds require HCP orders, NG tubes are premature, and OT is for rehabilitation, not immediate care.
Question 5 of 5
The nurse is caring for clients in an outpatient surgery clinic. Which client should be assessed first?
Correct Answer: A
Rationale: Crying suggests emotional distress or pain, requiring immediate assessment. Sleeping, voiding, and discharge-ready clients are stable.