ATI RN
NCLEX Questions on Skin Integrity and Wound Care Questions
Question 1 of 5
A 1-month-old infant is admitted to the hospital with a temperature of 102°F. What is the rationale for a complete septic workup?
Correct Answer: B
Rationale: The correct answer is B: Immature immune system. A 1-month-old infant has an underdeveloped immune system, making them more susceptible to infections. A temperature of 102°F suggests a potential serious infection like sepsis. A complete septic workup is necessary to identify the source of infection and initiate appropriate treatment promptly. Choices A, C, and D are incorrect because the absence of sweat glands, inadequate red blood cells, and poor lung elasticity do not directly relate to the need for a septic workup in this scenario.
Question 2 of 5
The most common type of upper urinary tract infection that results from bacteria ascending to the kidney from the lower respiratory tract is
Correct Answer: C
Rationale: The correct answer is C: pyelonephritis. This is because pyelonephritis is a type of upper urinary tract infection that occurs when bacteria ascends from the lower urinary tract to the kidney, often through the ureters. Urethritis (choice A) is an infection of the urethra, not the kidney. Prostatitis (choice B) is an infection of the prostate gland, not the kidney. Cystitis (choice D) is a lower urinary tract infection involving the bladder, not the kidney. Therefore, pyelonephritis is the most appropriate choice in this scenario.
Question 3 of 5
A client with a previously healed tuberculosis lesion experiences lesion rupture that leads to active disease. Which type of tuberculosis does this client have?
Correct Answer: C
Rationale: Rationale: 1. The client had a previously healed lesion, indicating latent infection. 2. Rupture led to active disease, suggesting reactivation of latent infection. 3. Therefore, the client has reactivation tuberculosis. Summary: - A: Miliary TB is widespread dissemination, not related to a single lesion. - B: Extrapulmonary TB affects organs other than the lungs. - D: Cavitation TB involves formation of cavities in the lungs, not directly related to lesion rupture.
Question 4 of 5
The nurse prepares to obtain a culture from a patient who has a possible fungal infection on the foot. Which items should the nurse gather for this procedure?
Correct Answer: A
Rationale: The correct answer is A: Sterile gloves. When obtaining a culture for a fungal infection, sterile gloves are essential to prevent contamination. The nurse needs to maintain aseptic technique to ensure accurate results and prevent potential spread of infection. Patch test instruments (B) are used for allergy testing, not for obtaining cultures. Cotton-tipped applicators (C) are usually used for wound care or specimen collection, but not ideal for obtaining fungal cultures. Syringe and intradermal needle (D) are typically used for administering medications or taking blood samples, not for fungal culture collection.
Question 5 of 5
Which information should the nurse include in the teaching plan for a patient diagnosed with basal cell carcinoma (BCC)?
Correct Answer: C
Rationale: The correct answer is C because minimizing sun exposure is crucial in preventing future basal cell carcinoma (BCC) development. Sun exposure is a major risk factor for BCC, so educating the patient on sun protection measures is essential. Choice A is incorrect as watchful waiting is not a typical treatment plan for BCC. Choice B is incorrect because BCC rarely metastasizes. Choice D is incorrect because systemic chemotherapy is not a common treatment for BCC. Overall, educating the patient on sun protection is key in managing and preventing BCC.