ATI RN
NCLEX Practice Questions Skin Integrity and Wound Care Questions
Question 1 of 5
The nurse in an urgent care center assesses a 40-year-old adult client who presents with a fever of 101.2°F and complaints of painful urination. What should the nurse ask to elicit further data that indicate cystitis?
Correct Answer: D
Rationale: The correct answer is D: "What color is your urine?" This question is essential to assess for cystitis because changes in urine color (such as cloudy or bloody urine) are common symptoms of this condition. Fever and painful urination are also typical symptoms of cystitis, so asking about urine color helps confirm the diagnosis. Choice A is incorrect because menopause symptoms are not relevant to the client's current presentation. Choice B is less pertinent as the duration of fever and presence of chills, while important, may not directly point to cystitis. Choice C is also less relevant as upper abdominal pain or cramping are not specific symptoms of cystitis.
Question 2 of 5
A dark-skinned patient has been admitted to the hospital with chronic heart failure. How would the nurse assess this patient for cyanosis?
Correct Answer: C
Rationale: The correct answer is C: Check the lips and oral mucous membranes. In patients with dark skin, cyanosis may not be as easily visible on the skin. Lips and oral mucous membranes are more reliable areas to assess for cyanosis due to their rich blood supply and transparency. Checking the lips and oral mucous membranes provides a more accurate indication of tissue oxygenation levels. Assessing the skin color of the earlobes (A) may not be as accurate in detecting cyanosis in dark-skinned individuals. Applying pressure to the palms of the hands (B) is not a standard method for assessing cyanosis. Examining capillary refill time of the nail beds (D) is more indicative of peripheral perfusion rather than cyanosis.
Question 3 of 5
Which information should the nurse include when teaching a patient who has just received a prescription for ciprofloxacin (Cipro) to treat a urinary tract infection?
Correct Answer: A
Rationale: The correct answer is A because ciprofloxacin can increase sensitivity to the sun, leading to sunburn. Using sunscreen with a high SPF can help protect the skin from harmful UV rays. This is important to prevent skin damage and sunburn while on the medication. Choices B, C, and D are incorrect because they do not directly address the issue of sun sensitivity caused by ciprofloxacin. B discusses the effectiveness of the medication, C talks about an artificial-looking tan, and D addresses eye damage rather than skin protection.
Question 4 of 5
A patient is undergoing psoralen plus ultraviolet A light (PUVA) therapy for treatment of psoriasis. What action should the nurse take to prevent adverse effects from this procedure?
Correct Answer: D
Rationale: The correct answer is D: Have the patient use protective eyewear while receiving PUVA. This is crucial to protect the patient's eyes from potential damage caused by exposure to UV light during the treatment. Failure to wear protective eyewear can lead to serious eye complications such as cataracts or damage to the cornea. Shielding unaffected areas with lead-lined drapes (choice A) is not necessary as the focus should be on protecting the eyes. Applying petroleum jelly (choice B) may interfere with the effectiveness of the treatment. Cleansing the skin with antiseptic soap (choice C) is not directly related to preventing adverse effects from PUVA therapy.
Question 5 of 5
The nurse is caring for a patient diagnosed with furunculosis. Which nursing action could the nurse delegate to unlicensed assistive personnel (UAP)?
Correct Answer: D
Rationale: The correct answer is D because cleaning the skin with antimicrobial soap is a task that can be safely delegated to UAP. This task does not require specialized nursing knowledge or assessment skills. It is within the scope of practice for UAP and is important in preventing the spread of infection. Applying antibiotic cream (choice A) and obtaining cultures (choice B) require specific nursing assessments and skills. Evaluating personal hygiene (choice C) involves assessment and critical thinking, which are beyond the scope of practice for UAP.