ATI RN
NCLEX Questions Skin Integrity and Wound Care Questions
Question 1 of 5
Based on the information in the accompanying figure obtained for a patient in the emergency room, which action will the nurse take first?
Correct Answer: C
Rationale: The correct answer is C: Check the patient’s O2 saturation using pulse oximetry. This is the first action the nurse should take because it directly assesses the patient's oxygen levels, which is crucial for determining the patient's immediate respiratory status and need for intervention. Monitoring oxygen saturation helps in identifying hypoxemia, which can be life-threatening and requires prompt attention. Administering morphine IV (choice A) could potentially worsen respiratory depression if the patient is already hypoxic. Contacting the operating room for surgery (choice B) is not appropriate without assessing the patient's oxygenation first. Asking about the date of the last tetanus immunization (choice D) is important but not the priority when the patient's oxygenation is in question.
Question 2 of 5
Which nursing action included in the care of a patient after laminectomy can the nurse delegate to experienced unlicensed assistive personnel (UAP)?
Correct Answer: C
Rationale: The correct answer is C because log rolling the patient from side to side every 2 hours is a task that can be safely delegated to experienced unlicensed assistive personnel (UAP). This task helps prevent complications such as pressure ulcers and promotes mobility without risking injury. A: Checking the ability to plantar and dorsiflex the foot requires clinical judgment and may indicate nerve damage, which should be assessed by a licensed nurse. B: Determining the patient's readiness to ambulate involves assessing strength, balance, and coordination, which requires nursing judgment and assessment skills. D: Asking about pain management with PCA involves assessing the effectiveness of the pain control method and potential side effects, which should be done by a licensed nurse.
Question 3 of 5
A client is exhibiting manifestations of superficial dermatophytosis of the skin with skin scaling and nail disintegration. Based on these findings, the nurse can anticipate that the client will be prescribed: Select all that apply.
Correct Answer: A
Rationale: Correct Answer: A - An antifungal like ketoconazole Rationale: Superficial dermatophytosis is a fungal infection of the skin and nails. Antifungals like ketoconazole are specifically designed to treat fungal infections, including dermatophytosis. They work by targeting and killing the fungus responsible for the infection. Therefore, prescribing an antifungal like ketoconazole would be appropriate in this case. Summary of Incorrect Choices: B: An antibiotic like tetracycline - Antibiotics are used to treat bacterial infections, not fungal infections like dermatophytosis. C: Topical corticosteroid - Corticosteroids are used to reduce inflammation and are not effective against fungal infections. D: An antihistamine like Benadryl - Antihistamines are used to treat allergic reactions and itching, not fungal infections.
Question 4 of 5
Dry, itchy plaques on her elbows and knees have prompted a 23-year-old woman to seek care. The clinician has subsequently diagnosed the client with psoriasis, a disorder that results from:
Correct Answer: A
Rationale: The correct answer is A: Increased epidermal cell turnover. Psoriasis is a chronic skin disorder characterized by rapid growth and shedding of skin cells. This results from an increased rate of epidermal cell proliferation, leading to the formation of dry, itchy plaques. Choice B, IgE-mediated immune reaction, is incorrect as psoriasis is not primarily an allergic reaction. Choice C, hormonal influences on sebaceous gland activity, is incorrect as psoriasis is not related to sebaceous gland function. Choice D, human papillomaviruses (HPV), is incorrect as HPV is not associated with psoriasis.
Question 5 of 5
Dysplastic nevi are precursors of malignant melanoma that are:
Correct Answer: A
Rationale: The correct answer is A: Larger than other nevi. Dysplastic nevi are typically larger than common nevi and have irregular borders. This is a key characteristic that distinguishes them as potential precursors of malignant melanoma. Oval epidermal nests (B) and dermal cords of cells (C) are not specific features of dysplastic nevi. Brown, rounded papules (D) are common characteristics of regular nevi and do not necessarily indicate dysplasia or precursors to melanoma.