ATI LPN
Fundamentals of Nursing Skin Integrity and Wound Care NCLEX Questions Questions
Question 1 of 5
In caring for a stage IV pressure ulcer, the nurse assesses creamy yellow drainage with a necrotic odor. Which type of bacteria most likely causes this exudate?
Correct Answer: C
Rationale: Creamy yellow drainage is usually caused by Staphylococcus infections. Proteus is associated with a beige discharge having a fishy odor. Brown discharge having a fecal odor is seen in Bacteroides. Pseudomonas-containing wounds produce a green-blue discharge with a fruity odor.
Question 2 of 5
A client is in the health care clinic for complaints of pruritus. Following diagnostic studies, it has been determined that there is not a pathophysiological process causing the pruritus. The nurse prepares instructions for the client to assist in reducing the problem and tells the client to:
Correct Answer: C
Rationale: A cool-mist vaporizer adds moisture to the air, reducing dryness-related pruritus, especially in winter.
Question 3 of 5
A nurse is preparing a plan of care for a client with a diagnosis of acute cellulitis of the lower leg. The nurse anticipates which measure will be prescribed to treat this condition?
Correct Answer: A
Rationale: Warm moist compresses promote vasodilation and enhance antibiotic delivery to the infected area in cellulitis.
Question 4 of 5
A nurse is aware that the outer layer of the skin consists of dead cells that contain large amounts of keratin. The physiologic functions of keratin include which of the following?
Correct Answer: C
Rationale: The dead cells of the epidermis contain large amounts of keratin, an insoluble, fibrous protein that forms the outer barrier of the skin. Keratin has the capacity to repel pathogens and prevent excessive fluid loss from the body. It does not contribute directly to antibody production or electrolyte absorption.
Question 5 of 5
A nurse is preparing to perform the physical assessment of a newly admitted patient. During which of the following components of the assessment should the nurse wear gloves?
Correct Answer: B
Rationale: Gloves are worn during skin examination if a rash or lesions are to be palpated. It is not normally necessary to wear gloves to palpate intact skin unless contact with body fluids is foreseeable.