ATI LPN
Skin Integrity NCLEX Questions Questions
Question 1 of 5
A nurse cares for a client who is prescribed vancomycin (Vancocin) 500 mg IV every 6 hours for a methicillin-resistant Staphylococcus aureus (MRSA) infection. Which action should the nurse take?
Correct Answer: C
Rationale: Vancomycin is very irritating to veins and can cause thrombophlebitis, requiring frequent IV site assessment.
Question 2 of 5
An emergency room nurse cares for a client admitted with a 50% burn injury at 10:00 this morning. The client weighs 90 kg. Using the Parkland formula, calculate the rate at which the nurse should infuse intravenous fluid resuscitation when started at noon.
Correct Answer: B
Rationale: Using the Parkland formula (4 mL/kg/% burn), 18,000 mL is needed in 24 hours; half (9000 mL) in the first 8 hours. Starting at noon, 9000 mL over 6 hours is 1500 mL/hr.
Question 3 of 5
A teenaged male patient who wrestles in high school is examined by the nurse in the clinic. Which assessment finding would prompt the nurse to teach the patient about the importance of not sharing headgear to prevent the spread of pediculosis?
Correct Answer: B
Rationale: Pediculosis is characterized by wheal-like lesions with parasites that attach eggs to the base of the hair shaft. The other descriptions are more characteristic of other types of skin disorders.
Question 4 of 5
The nurse is applying mafenide acetate (Sulfamylon), a sulfa antibiotic cream, to a client's lower extremity burn. Which assessment data would require immediate attention by the nurse?
Correct Answer: C
Rationale: The ABG values indicate metabolic acidosis (low HCO3), a known side effect of mafenide acetate, requiring immediate attention to prevent further complications.
Question 5 of 5
The female client admitted for an unrelated diagnosis asks the nurse to check her back because 'it itches all the time in that one spot.' When the nurse assesses the client's back, the nurse notes an irregular-shaped lesion with some scabbed-over areas surrounding the lesion. Which action should the nurse implement first?
Correct Answer: B
Rationale: Measuring and documenting the lesion provides objective data for further evaluation, the first step in assessment.