ATI LPN
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.