ATI LPN
NCLEX Skin Integrity Questions Questions
Question 1 of 5
The nurse in a medical unit is caring for a client with heart failure. The client suddenly develops extreme dyspnea, tachycardia, and lung crackles and the nurse suspects pulmonary edema. Which intervention is the priority?
Correct Answer: A
Rationale: Oxygen is the priority in pulmonary edema to correct hypoxemia. Originally multi-select, restructured to single-answer focusing on the most immediate need.
Question 2 of 5
A client has just been admitted to the nursing unit following thyroidectomy. Which assessment is the priority for this client?
Correct Answer: C
Rationale: Respiratory distress is the priority post-thyroidectomy due to potential airway obstruction from swelling or hematoma, a life-threatening complication requiring immediate attention.
Question 3 of 5
The nurse has staged a pressure injury that has a shallow crater with a dry pink wound bed as a:
Correct Answer: B
Rationale: Stage 2 pressure injuries appear as a shallow open injury, usually shiny or dry, with a red-pink wound bed without slough.
Question 4 of 5
Which of the following is a nursing intervention for the treatment of head lice and scabies?
Correct Answer: A
Rationale: Identify involved contacts while stressing importance of preventing transmission of disease. Washable and clothing items should be cleaned in hot water to prevent reinfection. No special diet or isolation is required once medical management is completed. This question was restructured from a multiple-response format.
Question 5 of 5
The nurse is caring for a burn patient. Which action best prevents contractures?
Correct Answer: A
Rationale: While each of these interventions is important for management of the patient with burns, only ambulation works to prevent contractures. Other interventions address pain management, adequate hydration, and adequate nutritional intake.