ATI RN
Skin Integrity and Wound Care NCLEX Questions Questions
Question 1 of 5
An adult client is admitted to the hospital with a diagnosis of kidney stones. The healthcare provider prescribes IV fluids, x-rays, blood work, and a Foley catheter for the client. The nurse is caring for the client 3 days after admission and documents morning vital signs of 101°F, heart rate 92, respirations 25, and blood pressure 120/80. The urinary output has decreased, and the urine is cloudy and dark amber. Based on this data, which conclusion by the nurse is the most appropriate?
Correct Answer: D
Rationale: The correct answer is D: The client has a probable urinary tract infection. The rationale is as follows: 1. Cloudy and dark amber urine is indicative of possible infection in the urinary tract. 2. Decreased urinary output along with abnormal urine color suggests an issue with the urinary system. 3. Fever, elevated heart rate, and increased respiratory rate can indicate a systemic response to infection. 4. The combination of clinical findings points towards a urinary tract infection rather than kidney stones, renal failure, or respiratory infection. Summary: Options A, B, and C are incorrect because they do not align with the client's clinical presentation, which strongly suggests a urinary tract infection based on the combination of symptoms and signs observed.
Question 2 of 5
A patient has the following risk factors for melanoma. Which risk factor should the nurse assign as the priority focus of patient teaching?
Correct Answer: B
Rationale: Step 1: Tanning booth use is a modifiable risk factor, unlike the patient's genetic predisposition (A) or inherent characteristics (C). Step 2: Tanning booths increase UV exposure, a known risk factor for melanoma. Step 3: Education on avoiding tanning booths can help reduce the patient's risk. Summary: Option B is the priority as it addresses a behavior that can be changed to lower melanoma risk, unlike the other factors.
Question 3 of 5
What is the best method to prevent the spread of infection to others when the nurse is changing the dressing over a wound infected with Staphylococcus aureus?
Correct Answer: C
Rationale: The correct answer is C: Wash hands and properly dispose of soiled dressings. This is the best method to prevent the spread of infection when changing the dressing over a wound infected with Staphylococcus aureus. Washing hands helps to remove any potential pathogens, reducing the risk of cross-contamination. Proper disposal of soiled dressings ensures that any infectious material is contained and not spread to others. Incorrect options: A: Changing the dressing using sterile gloves is important, but it is not sufficient on its own to prevent the spread of infection. B: Applying antibiotic ointment over the wound may help treat the infection locally but does not address the risk of spreading the infection. D: Soaking the dressing in sterile normal saline before removal may help with the removal process, but it does not address preventing the spread of infection to others.
Question 4 of 5
The nurse working in the dermatology clinic assesses a young adult female patient who has severe cystic acne. Which assessment finding is of concern related to the patient’s prescribed isotretinoin?
Correct Answer: A
Rationale: The correct answer is A because isotretinoin is a teratogenic medication, meaning it can cause severe birth defects if taken during pregnancy. Therefore, it is crucial for females of childbearing age to use effective contraception while on isotretinoin to prevent pregnancy. The removal of the intrauterine device raises concerns about the patient's contraception method and potential risk of pregnancy. Choice B is incorrect because acne scarring does not directly impact the safety or effectiveness of isotretinoin treatment. Choice C is incorrect as the use of topical antibiotics does not directly affect the use of isotretinoin. Choice D is incorrect as a family history of rheumatoid arthritis is not a contraindication or concern specifically related to isotretinoin treatment.
Question 5 of 5
After completing the health history, the nurse assessing the musculoskeletal system will begin by
Correct Answer: C
Rationale: The correct answer is C because observing the patient's body build and muscle configuration provides initial information about the patient's overall musculoskeletal health. This step allows the nurse to assess for any abnormalities, such as muscle atrophy or asymmetry, which can indicate underlying musculoskeletal issues. It also helps in identifying any deformities or structural abnormalities. Choice A is incorrect because having the patient move the extremities against resistance comes later in the assessment process to evaluate muscle strength. Choice B is incorrect as feeling for crepitus during joint movement is a specific assessment for joint health and does not address the overall musculoskeletal system. Choice D is incorrect as checking active and passive range of motion for the extremities is typically done after observing the patient's body build and muscle configuration.