Following a severe corneal ulcer, the client had keratoplasty (corneal transplant). What nursing care should be included in the plan of care?

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Skin Integrity NCLEX Questions Questions

Question 1 of 5

Following a severe corneal ulcer, the client had keratoplasty (corneal transplant). What nursing care should be included in the plan of care?

Correct Answer: A

Rationale: Eye-shields protect the transplant, avoiding pressure-increasing activities aids healing, reporting changes detects complications, and sterile technique prevents infection. Mydriatics are not used postoperatively as they increase pressure.

Question 2 of 5

A nurse assesses a client who has open lesions. Which action should the nurse take first?

Correct Answer: A

Rationale: Nurses should wear gloves as part of Standard Precautions when examining skin that is not intact. The other options should be completed after gloves are put on.

Question 3 of 5

A nurse cares for a client who is prescribed vancomycin (Vancocin) 500 mg IV every 6 hours for a methicillin-resistant Staphylococcus aureus (MRSA) infection. Which action should the nurse take?

Correct Answer: C

Rationale: Vancomycin is very irritating to veins and can cause thrombophlebitis, requiring frequent IV site assessment.

Question 4 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 5 of 5

An emergency room nurse cares for a client admitted with a 50% burn injury at 10:00 this morning. The client weighs 90 kg. Using the Parkland formula, calculate the rate at which the nurse should infuse intravenous fluid resuscitation when started at noon.

Correct Answer: B

Rationale: Using the Parkland formula (4 mL/kg/% burn), 18,000 mL is needed in 24 hours; half (9000 mL) in the first 8 hours. Starting at noon, 9000 mL over 6 hours is 1500 mL/hr.

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