ATI RN
NCLEX Practice Questions Skin Integrity and Wound Care Questions
Question 1 of 5
A dark-skinned patient has been admitted to the hospital with chronic heart failure. How would the nurse assess this patient for cyanosis?
Correct Answer: C
Rationale: The correct answer is C: Check the lips and oral mucous membranes. In patients with dark skin, cyanosis may not be as easily visible on the skin. Lips and oral mucous membranes are more reliable areas to assess for cyanosis due to their rich blood supply and transparency. Checking the lips and oral mucous membranes provides a more accurate indication of tissue oxygenation levels. Assessing the skin color of the earlobes (A) may not be as accurate in detecting cyanosis in dark-skinned individuals. Applying pressure to the palms of the hands (B) is not a standard method for assessing cyanosis. Examining capillary refill time of the nail beds (D) is more indicative of peripheral perfusion rather than cyanosis.
Question 2 of 5
A patient is undergoing psoralen plus ultraviolet A light (PUVA) therapy for treatment of psoriasis. What action should the nurse take to prevent adverse effects from this procedure?
Correct Answer: D
Rationale: The correct answer is D: Have the patient use protective eyewear while receiving PUVA. This is crucial to protect the patient's eyes from potential damage caused by exposure to UV light during the treatment. Failure to wear protective eyewear can lead to serious eye complications such as cataracts or damage to the cornea. Shielding unaffected areas with lead-lined drapes (choice A) is not necessary as the focus should be on protecting the eyes. Applying petroleum jelly (choice B) may interfere with the effectiveness of the treatment. Cleansing the skin with antiseptic soap (choice C) is not directly related to preventing adverse effects from PUVA therapy.
Question 3 of 5
The nurse is caring for a patient diagnosed with furunculosis. Which nursing action could the nurse delegate to unlicensed assistive personnel (UAP)?
Correct Answer: D
Rationale: The correct answer is D because cleaning the skin with antimicrobial soap is a task that can be safely delegated to UAP. This task does not require specialized nursing knowledge or assessment skills. It is within the scope of practice for UAP and is important in preventing the spread of infection. Applying antibiotic cream (choice A) and obtaining cultures (choice B) require specific nursing assessments and skills. Evaluating personal hygiene (choice C) involves assessment and critical thinking, which are beyond the scope of practice for UAP.
Question 4 of 5
Which information obtained during the nurse’s assessment of a patient’s nutritional-metabolic pattern may indicate increased risk for musculoskeletal problems?
Correct Answer: C
Rationale: The correct answer is C because the patient being 5 ft, 2 in tall and weighing 180 lb indicates potential obesity, which can increase the risk for musculoskeletal problems. Excess weight puts strain on the bones and joints, leading to conditions like osteoarthritis. A: Taking a multivitamin daily is generally positive for overall health but does not directly indicate an increased risk for musculoskeletal problems. B: Disliking fruits and vegetables may point to potential nutritional deficiencies but does not directly indicate musculoskeletal issues. D: Preferring whole milk over nonfat milk may impact overall nutritional intake but is not directly linked to musculoskeletal problems. In summary, choice C is correct because obesity is a significant risk factor for musculoskeletal problems, while choices A, B, and D do not directly indicate an increased risk in this context.
Question 5 of 5
Which finding from analysis of fluid from a patient’s right knee arthrocentesis will be of concern to the nurse?
Correct Answer: A
Rationale: The correct answer is A: Cloudy fluid. Cloudy fluid from knee arthrocentesis indicates the presence of infection or inflammation, which can be concerning for the nurse. This finding suggests the presence of pus, white blood cells, or microorganisms in the fluid, indicating a possible septic joint. Scant thin fluid (B) is not concerning as it may indicate a non-inflammatory condition. Pale yellow (C) and straw-colored (D) fluids are normal findings in arthrocentesis and do not raise concerns for infection or inflammation.