ATI RN
Skin Integrity and Wound Care NCLEX Questions Questions
Question 1 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 2 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 3 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 4 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.
Question 5 of 5
What is the best method to prevent the spread of infection to others when the nurse is changing the dressing over a wound infected with Staphylococcus aureus?
Correct Answer: C
Rationale: The correct answer is C: Wash hands and properly dispose of soiled dressings. This is the best method to prevent the spread of infection when changing the dressing over a wound infected with Staphylococcus aureus. Washing hands helps to remove any potential pathogens, reducing the risk of cross-contamination. Proper disposal of soiled dressings ensures that any infectious material is contained and not spread to others. Incorrect options: A: Changing the dressing using sterile gloves is important, but it is not sufficient on its own to prevent the spread of infection. B: Applying antibiotic ointment over the wound may help treat the infection locally but does not address the risk of spreading the infection. D: Soaking the dressing in sterile normal saline before removal may help with the removal process, but it does not address preventing the spread of infection to others.