ATI RN
Skin Integrity and Wound Care NCLEX Questions Questions
Question 1 of 5
The nurse is caring for a client who has been diagnosed with orbital cellulitis. Which assessment finding should the nurse anticipate?
Correct Answer: B
Rationale: The correct answer is B: Edema of the affected eye. Orbital cellulitis is characterized by inflammation and infection of the tissues surrounding the eye, leading to swelling and edema. This assessment finding is expected due to the inflammatory response. Sunken eyes (A) are not typically associated with orbital cellulitis. Increased acuity of the affected eye (C) is unlikely as the infection can impair vision. Elevated blood pressure (D) is not a typical assessment finding for orbital cellulitis.
Question 2 of 5
What should the nurse recommend for a pregnant client who is concerned about a recent flu outbreak?
Correct Answer: A
Rationale: The correct answer is A. The nurse should recommend that the client receive the influenza vaccination because it is safe during pregnancy and helps protect both the mother and the baby from potential complications of the flu. Vaccination is the most effective way to prevent flu infection. Choice B is incorrect because staying home does not provide the same level of protection as vaccination. Choice C is incorrect as amantadine is not recommended during pregnancy due to potential risks to the fetus. Choice D is incorrect as while a healthy diet is important, it is not sufficient to protect against the flu during pregnancy.
Question 3 of 5
The nurse is teaching the parents of an infant who is diagnosed with acute otitis media. Which is the priority teaching point for these parents?
Correct Answer: C
Rationale: The correct answer is C: Administer acetaminophen to relieve pain and decrease fever. This is the priority teaching point as it addresses the immediate symptoms of acute otitis media, providing comfort to the infant. Decongestants (choice A) are not typically recommended for infants with otitis media. Keeping the baby in a flat position during sleep (choice B) can increase the risk of ear infections. Using a pacifier (choice D) is not directly related to managing the symptoms of otitis media. Acetaminophen is safe and effective for reducing pain and fever in infants, making it the most appropriate choice in this scenario.
Question 4 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 5 of 5
The nurse is caring for an older adult client who developed sepsis from a pressure ulcer while residing in a long-term care facility. The family asks how they can help prevent this from happening again in the future. Which response by the nurse is best?
Correct Answer: D
Rationale: Correct Answer: D. Assist the client with meals to obtain optimal nourishment. Rationale: 1. Optimal nourishment is crucial for the client's immune system to fight off infection. 2. Malnutrition can weaken the body's ability to heal and recover. 3. Adequate nutrition is essential for tissue repair and prevention of pressure ulcers. Summary: A: Alerting the staff about the IV is important but not directly related to preventing pressure ulcers. B: Helping with dressing changes is beneficial, but nutrition plays a more significant role in preventing sepsis. C: Assisting the client to the bathroom is important for fall prevention but does not directly address the underlying cause of sepsis from pressure ulcers.