ATI LPN
Skin Integrity NCLEX Questions Questions
Question 1 of 5
An emergency room nurse assesses a client who was rescued from a home fire. The client suddenly develops a loud, brassy cough. Which action should the nurse take first?
Correct Answer: A
Rationale: A brassy cough indicates possible inhalation injury, requiring immediate oxygen and monitoring.
Question 2 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 3 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 4 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.
Question 5 of 5
The nurse is teaching a class on how to prevent Lyme disease. Which intervention should be included in the discussion?
Correct Answer: C
Rationale: Avoiding dense undergrowth reduces tick exposure, a primary prevention strategy for Lyme disease.