ATI RN
NCLEX Questions on Skin Integrity and Wound Care Questions
Question 1 of 5
An adolescent client is brought to the emergency department (ED) with fatigue, weight loss, a dry cough, and night sweats. The family just recently immigrated to the United States. Based on this data, which potential risk should the nurse include when planning care for this client?
Correct Answer: A
Rationale: The correct answer is A: Pneumothorax. Given the symptoms of fatigue, weight loss, dry cough, and night sweats in an adolescent who recently immigrated, the nurse should consider tuberculosis (TB) as a potential risk. TB can lead to pneumothorax due to lung cavitation and can present with the symptoms described. Atelectasis, renal failure, and reduced peristalsis are less likely in this scenario and do not align with the client's presenting symptoms and recent immigration history.
Question 2 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 3 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 4 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.
Question 5 of 5
A patient with an enlarging, irregular mole that is 7 mm in diameter is scheduled for outpatient treatment. The nurse should plan to prepare the patient for which procedure?
Correct Answer: D
Rationale: The correct answer is D: Surgical excision. This is the most appropriate procedure for removing a suspicious mole that is irregular, enlarging, and potentially malignant. Surgical excision allows for the complete removal of the mole along with a margin of healthy tissue to ensure that all abnormal cells are eliminated. Curettage (A) involves scraping the skin surface and may not be sufficient for complete removal. Cryosurgery (B) freezes and destroys tissue but may not be adequate for excising a potentially malignant lesion. Punch biopsy (C) is used for sampling a small portion of the mole for diagnostic purposes, not for complete removal.