ATI RN
Skin Integrity and Wound Care NCLEX Questions Questions
Question 1 of 5
The nurse is caring for a client who develops a fever and productive cough after abdominal surgery. Which orders should the nurse expect from the healthcare provider? Select all that apply.
Correct Answer: C
Rationale: The correct answer is C: Chest physiotherapy. After abdominal surgery, the client is at risk for developing atelectasis due to shallow breathing and ineffective coughing. Chest physiotherapy helps improve lung expansion and secretion clearance, preventing complications like pneumonia. Sputum cultures (A) and bronchial washing for culture (D) are not typically indicated in this scenario unless there are specific indications such as suspected infection. Antibiotics (B) should not be given prophylactically without evidence of infection. In summary, chest physiotherapy is essential for preventing respiratory complications post-abdominal surgery, while the other options are not necessary unless there are specific indications.
Question 2 of 5
The nurse is planning care for a client recently diagnosed with tuberculosis (TB). The client lives alone in an apartment and will continue treatment at home. When reviewing the client's history, the nurse notes that the client has had trouble complying with medication regimens in the past. Which nursing diagnosis is a priority for this client?
Correct Answer: A
Rationale: The correct answer is A: Ineffective Health Management. This is because the client's history of noncompliance with medication regimens indicates a potential risk for ineffective management of their health. This diagnosis is a priority as ensuring adherence to TB treatment is crucial for the client's health and preventing the spread of the disease. Choice B: Deficient Knowledge may not be the priority as the client's issue seems to be related to compliance rather than lack of knowledge. Choice C: Ineffective Breathing Pattern and Choice D: Risk for Injury are not as directly related to the client's history of medication noncompliance. The priority is to address the client's difficulty in managing their health effectively.
Question 3 of 5
A mother brings in her 6-year-old daughter with signs and symptoms of fever, reduced voiding, uncontrolled voiding, and pain during urination. The daughter is diagnosed with a urinary tract infection. Which nursing outcome is most appropriate for this client?
Correct Answer: B
Rationale: The correct answer is B: The client will report no episodes of enuresis. Enuresis refers to involuntary urination, which can be a common symptom of urinary tract infection in children. Achieving no episodes of enuresis indicates successful treatment and resolution of the infection. This outcome specifically addresses the client's urinary symptoms, making it the most appropriate choice. Choice A is incorrect as it focuses on bilirubin levels, which are not directly related to urinary tract infection. Choice C is incorrect as remaining afebrile for 12 hours does not address the urinary symptoms. Choice D is incorrect as it only focuses on the volume of urine voided and does not address the resolution of the infection or the client's symptoms.
Question 4 of 5
An adult client is admitted to the hospital with a diagnosis of kidney stones. The healthcare provider prescribes IV fluids, x-rays, blood work, and a Foley catheter for the client. The nurse is caring for the client 3 days after admission and documents morning vital signs of 101°F, heart rate 92, respirations 25, and blood pressure 120/80. The urinary output has decreased, and the urine is cloudy and dark amber. Based on this data, which conclusion by the nurse is the most appropriate?
Correct Answer: D
Rationale: The correct answer is D: The client has a probable urinary tract infection. The rationale is as follows: 1. Cloudy and dark amber urine is indicative of possible infection in the urinary tract. 2. Decreased urinary output along with abnormal urine color suggests an issue with the urinary system. 3. Fever, elevated heart rate, and increased respiratory rate can indicate a systemic response to infection. 4. The combination of clinical findings points towards a urinary tract infection rather than kidney stones, renal failure, or respiratory infection. Summary: Options A, B, and C are incorrect because they do not align with the client's clinical presentation, which strongly suggests a urinary tract infection based on the combination of symptoms and signs observed.
Question 5 of 5
A patient in the dermatology clinic is scheduled for removal of a 15-mm multicolored and irregular mole from the upper back. The nurse should prepare the patient for which type of biopsy?
Correct Answer: D
Rationale: The correct answer is D: Excisional biopsy. This type of biopsy is appropriate for the removal of a larger lesion like a 15-mm mole. It involves removing the entire lesion along with a margin of normal tissue for accurate diagnosis. Shave biopsy (A) is superficial and not suitable for larger or irregular lesions. Punch biopsy (B) removes a small cylindrical core of tissue and may not be sufficient for comprehensive analysis. Incisional biopsy (C) involves taking a sample from a specific area of the lesion, which is not ideal for suspicious or multicolored moles as they require complete removal for accurate assessment.