ATI RN
Skin Integrity and Wound Care NCLEX Questions Questions
Question 1 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.
Question 2 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 3 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 4 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.
Question 5 of 5
A patient has the following risk factors for melanoma. Which risk factor should the nurse assign as the priority focus of patient teaching?
Correct Answer: B
Rationale: Step 1: Tanning booth use is a modifiable risk factor, unlike the patient's genetic predisposition (A) or inherent characteristics (C). Step 2: Tanning booths increase UV exposure, a known risk factor for melanoma. Step 3: Education on avoiding tanning booths can help reduce the patient's risk. Summary: Option B is the priority as it addresses a behavior that can be changed to lower melanoma risk, unlike the other factors.