ATI LPN
NCLEX Skin Integrity Questions Questions
Question 1 of 5
The nurse is assisting with the secondary survey of a patient with 50% total body surface area electrical burns. Which test would be a priority for this patient?
Correct Answer: D
Rationale: Electrical burns can cause cardiac arrhythmias due to current passing through the body, making a 12-lead ECG a priority to assess heart function.
Question 2 of 5
The nurse sends 10 samples of body sites to assess an intensive care patient's Candida colonization index. Seven of the samples came back as being positive. What is this patient's colonization index?
Correct Answer: B
Rationale: The colonization index is calculated as the ratio of positive sites to total sites (7/10 = 0.7), indicating significant Candida presence.
Question 3 of 5
If a 35 year old female has a thigh measurement of 34 mm, iliac crest of 12 mm, and triceps of 25 mm, what is her percent body fat?
Correct Answer: B
Rationale: Using the Jackson-Pollock 3-site formula for women: sum = 71 mm, body fat ≈ 25% (exact calculation varies by chart, but 25% is typical).
Question 4 of 5
A female client with a severe staphylococcal infection is receiving the aminoglycoside gentamicin sulfate (Garamycin) by the I.V. route. The nurse should assess the client for which adverse reaction to this drug.
Correct Answer: B
Rationale: Gentamicin is known to cause ototoxicity, potentially leading to hearing loss or balance issues, requiring close monitoring.
Question 5 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.