ATI LPN
NCLEX Skin Integrity Questions Questions
Question 1 of 5
Nurse Harry documents the presence of a scab on a client's deep wound. The nurse identifies this as which phase of wound healing?
Correct Answer: B
Rationale: The migratory phase involves epithelial cell migration and scab formation as the wound begins to close.
Question 2 of 5
A school-age child has been prescribed magic mouthwash for gingival herpes simplex type I(HSV-1) infection. The parent asks how this helps the childs condition. Which response by the nurse is the most appropriate?
Correct Answer: A
Rationale: Magic mouthwash has several recipes, but common ingredients include Benadryl, lidocaine, and Mylanta, which all help increase comfort so the child continues to eat and drink.
Question 3 of 5
A nurse is caring for four patients on a general pediatric unit. The nurse identifies risk for impaired skin integrity as a nursing diagnosis for all four. Which patients skin should the nurse assess first?
Correct Answer: D
Rationale: Immobility is a major risk factor for impaired skin integrity. The nurse should first assess the child in traction, as this child is the least mobile.
Question 4 of 5
Which intervention should the nurse implement for a client diagnosed with a full-thickness burn over 38% of the body admitted to the burn unit 4 hours after the fire, with an HCP order for Ringer's lactate 450 mL/hour?
Correct Answer: B
Rationale: The nurse should administer the IV fluid as prescribed and infuse it via a pump to ensure accurate delivery. Fluid resuscitation formulas specify large volumes (50% in the first 8 hours, 50% over the next 16 hours) for burns over 20% TBSA, making 450 mL/hour appropriate. Questioning the order or limiting to 200 mL/hour is incorrect, and verification with another nurse is unnecessary.
Question 5 of 5
The HCP ordered lindane to be administered to the client from an extended care facility who is diagnosed with scabies. Which intervention should the nurse implement?
Correct Answer: B
Rationale: For scabies, bathe the client, apply lindane lotion from neck down (avoiding face/meatus), and remove after 8-12 hours. Scalp application is for lice, scraping isn't done, and shampooing is incorrect for scabies.