ATI RN
NCLEX Practice Questions Skin Integrity and Wound Care Questions
Question 1 of 5
The nurse is caring for a client with pneumonia. Which intervention should the nurse include in this client's plan of care to promote effective airway clearance?
Correct Answer: A
Rationale: The correct answer is A because chest percussion helps loosen and mobilize secretions in the lungs, promoting effective airway clearance in pneumonia. It should be performed regularly to prevent mucus buildup. B: Administering the pneumococcal vaccine is important for preventing pneumonia but does not directly address airway clearance. C: Limiting fluid intake may lead to dehydration and thickening of secretions, worsening airway clearance. D: Smoking cessation education is important for overall lung health but does not directly address airway clearance in pneumonia.
Question 2 of 5
The nurse is preparing to assess an older adult client admitted with tuberculosis. Which assessment finding does the nurse anticipate?
Correct Answer: C
Rationale: The correct answer is C: Cough. In tuberculosis, a persistent cough is a common symptom due to infection of the lungs. This is caused by the Mycobacterium tuberculosis bacteria affecting the respiratory system. Night sweats (A) are also common in tuberculosis but are not specific to this condition. Swollen lymph nodes (B) typically occur in other infections such as bacterial or viral illnesses. Hemoptysis (D), which is coughing up blood, is a severe symptom seen in advanced stages of tuberculosis but not an early assessment finding.
Question 3 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 4 of 5
The nurse caring for a client at risk for tuberculosis (TB) should include which symptoms of the disease when educating the client? Select all that apply.
Correct Answer: A
Rationale: Step 1: Fatigue is a common symptom of tuberculosis due to the body's immune response to the infection. Step 2: Low-grade morning fever is not specific to TB and can be seen in various other infections. Step 3: A productive cough that later turns dry is more characteristic of other respiratory conditions, not necessarily TB. Step 4: Weight loss is a common symptom of TB due to the body's increased metabolic demands fighting the infection. Summary: Fatigue is directly related to the body's response to TB infection, making it a key symptom to educate the client about. Other choices are less specific to TB and may be seen in various other conditions.
Question 5 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.