ATI RN
NCLEX Practice Questions Skin Integrity and Wound Care Questions
Question 1 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 2 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 3 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.
Question 4 of 5
Which information should the nurse include when teaching a patient who has just received a prescription for ciprofloxacin (Cipro) to treat a urinary tract infection?
Correct Answer: A
Rationale: The correct answer is A because ciprofloxacin can increase sensitivity to the sun, leading to sunburn. Using sunscreen with a high SPF can help protect the skin from harmful UV rays. This is important to prevent skin damage and sunburn while on the medication. Choices B, C, and D are incorrect because they do not directly address the issue of sun sensitivity caused by ciprofloxacin. B discusses the effectiveness of the medication, C talks about an artificial-looking tan, and D addresses eye damage rather than skin protection.
Question 5 of 5
A patient is undergoing psoralen plus ultraviolet A light (PUVA) therapy for treatment of psoriasis. What action should the nurse take to prevent adverse effects from this procedure?
Correct Answer: D
Rationale: The correct answer is D: Have the patient use protective eyewear while receiving PUVA. This is crucial to protect the patient's eyes from potential damage caused by exposure to UV light during the treatment. Failure to wear protective eyewear can lead to serious eye complications such as cataracts or damage to the cornea. Shielding unaffected areas with lead-lined drapes (choice A) is not necessary as the focus should be on protecting the eyes. Applying petroleum jelly (choice B) may interfere with the effectiveness of the treatment. Cleansing the skin with antiseptic soap (choice C) is not directly related to preventing adverse effects from PUVA therapy.