ATI RN
NCLEX Questions Skin Integrity and Wound Care Questions
Question 1 of 5
A nurse is caring for a client with septicemia. What assessment by the nurse best addresses the potential for ineffective peripheral perfusion?
Correct Answer: D
Rationale: The correct answer is D: Monitor for cyanosis. In septicemia, inadequate peripheral perfusion can lead to cyanosis due to decreased oxygen delivery. Cyanosis is a late sign of compromised perfusion. Assessing heart rate (choice A) may indicate changes in cardiac function but does not directly assess peripheral perfusion. Monitoring temperature (choice B) can reveal fever, which is common in septicemia, but does not directly assess perfusion. Checking pupil reactions (choice C) is important but does not specifically address peripheral perfusion. Therefore, monitoring for cyanosis is the most direct way to assess for ineffective peripheral perfusion in a client with septicemia.
Question 2 of 5
The most common source for bacteria that cause a urinary tract infection is
Correct Answer: B
Rationale: The correct answer is B because the mucous membranes of the perineal area, located near the urinary tract, are a common entry point for bacteria causing UTIs. Bacteria from the perineal area can easily travel to the urinary tract and cause an infection. A catheter (A) may introduce bacteria but is not the most common source. Hands (C) can transfer bacteria, but the perineal area is more direct. Clothing (D) is unlikely to be a primary source of UTI-causing bacteria.
Question 3 of 5
The infecting organism that causes tuberculosis is
Correct Answer: D
Rationale: The correct answer is D: Mycobacterium tuberculosis. Mycobacterium tuberculosis is the causative organism of tuberculosis, a bacterial infection affecting the lungs. The genus Mycobacterium includes various species, but M. tuberculosis specifically causes tuberculosis. Micrococcus tuberculosis (A) and Microbacterium tuberculosis (B) are not valid scientific names. Mycoplasma tuberculosis (C) is incorrect as Mycoplasma is a different genus known for lacking a cell wall and causing different types of infections.
Question 4 of 5
When performing a skin assessment, the nurse notes angiomas on the chest of an older patient. Which action should the nurse take next?
Correct Answer: B
Rationale: The correct answer is B because angiomas on the chest can be a sign of liver disease. The nurse should assess the patient for other signs of liver disease, such as jaundice or abdominal distension. This can help in early detection and management of liver issues. Choice A is incorrect as referring to a dermatologist would not address the underlying cause of the angiomas. Choice C is incorrect as it does not address the potential health concern indicated by the angiomas. Choice D is incorrect as it does not address the specific issue of liver disease associated with angiomas.
Question 5 of 5
A patient in the dermatology clinic has a thin, scaly erythematous plaque on the right cheek. Which action should the nurse take?
Correct Answer: A
Rationale: The correct answer is A because a thin, scaly erythematous plaque may indicate skin cancer, such as squamous cell carcinoma. A skin biopsy is crucial to confirm the diagnosis and determine the appropriate treatment plan. Choice B is incorrect as corticosteroid cream is not suitable for potential skin cancer. Choice C is incorrect as tretinoin is mainly used for acne and photoaging, not for suspected skin cancer. Choice D is incorrect as antibiotics are not typically indicated for non-infectious skin conditions like squamous cell carcinoma.