ATI RN
NCLEX Skin Integrity Questions Questions
Question 1 of 5
A client receiving intravenous antibiotics for 3 days as treatment for cellulitis is being prepared for discharge. Which discharge order should the nurse anticipate for this client?
Correct Answer: C
Rationale: The correct answer is C: Oral antibiotics to be continued at home. This is the most appropriate discharge order as the client with cellulitis may need to continue antibiotic therapy beyond the IV treatment to ensure complete resolution of the infection. Continuing oral antibiotics at home helps prevent recurrence and promotes full recovery. A: Low-sodium diet prescribed - While a healthy diet is important, it is not directly related to the treatment of cellulitis. B: Home healthcare aide for the client - This may be needed for some clients, but it is not the priority in this case. D: Orders for evaluation by physical therapy - Physical therapy is not typically indicated for cellulitis treatment, so this would not be the most relevant discharge order.
Question 2 of 5
Which interventions should the nurse incorporate into the plan of care for a client diagnosed with influenza? Select the one that does not apply
Correct Answer: B
Rationale: Correct Answer: B - Placing the client in a negative air flow room does not apply. Influenza is primarily spread through respiratory droplets and contact, not airborne transmission. Therefore, a negative air flow room is not necessary. Rationale: A: Placing droplet and contact precaution signs is important to alert staff and visitors to take necessary precautions. C: Placing a ventilator is not necessary for influenza treatment, as it is a respiratory infection, not a condition requiring mechanical ventilation. D: Notifying other departments is crucial for infection control and prevention, to ensure appropriate measures are taken to prevent the spread of influenza.
Question 3 of 5
Which instruction should the nurse provide to an adolescent client with otitis media with regard to pain?
Correct Answer: B
Rationale: The correct answer is B: Report abrupt relief of pain immediately. This instruction is important because sudden relief of pain in otitis media may indicate rupture of the eardrum, which requires immediate medical attention. Applying a cold compress (A) may provide temporary relief but does not address the underlying issue. Continuing air travel (C) can worsen otitis media due to changes in air pressure. Reporting increased pain when moving the outer ear (D) may indicate an external ear infection, not specific to otitis media.
Question 4 of 5
The nurse is caring for an older adult client who is hospitalized with a second episode of pneumonia in the past 18 months. The client has expressed frustration to the nurse and states, 'I never got sick when I was younger. Why is this happening?' Which response by the nurse is most appropriate?
Correct Answer: B
Rationale: The correct answer is B because as individuals age, there is a natural decline in the immune response known as immunosenescence. This leads to a decreased ability to fight off infections like pneumonia, making older adults more susceptible. Option A is incorrect as the immune system doesn't simply stop working with age. Option C is incorrect because aging actually leads to a decline in immune response speed and strength. Option D is incorrect as an increase in B cells would not hinder the immune response but rather indicates a potential boost in antibody production.
Question 5 of 5
A client is admitted to the intensive care unit with a systemic infection. Which manifestations will the nurse most likely assess in this client? Select all that apply.
Correct Answer: D
Rationale: The correct answer is D: Hypotension. In systemic infection, the body's response often leads to widespread inflammation and vasodilation, resulting in decreased blood pressure. This can lead to hypotension due to decreased vascular resistance. Tachycardia (A) may also be present as the body compensates for low blood pressure by increasing heart rate. Pain (B) and Edema (C) are less likely to be directly associated with systemic infection and are not typical manifestations.