ATI LPN
Skin Integrity NCLEX Questions Questions
Question 1 of 5
The nurse is preparing to send a culture for a patient who has a possible herpes zoster infection on the chest. Which action is appropriate?
Correct Answer: A
Rationale: For lesions with vesicles or bullae, the lesion should be opened using sterile technique and a specimen obtained from the center of the lesion. Aspiration of bullae would present a risk of injury to the patient. Swabbing the area would be likely to result in obtaining normal skin flora rather than the infectious agent. Anaerobic cultures would be unnecessary for an infection on the skin of the chest and would unnecessarily increase the cost of the culture.
Question 2 of 5
Tissue damage from burn injury activates an inflammatory response that increases the patient's risk for:
Correct Answer: C
Rationale: The loss of skin as the primary barrier against microorganisms and activation of the inflammatory response cascades results in immunosuppression, placing the patient at an increased risk of infection. A systemic inflammatory response(SIRS) also increases the risk of acute kidney injury in the presence of poor tissue perfusion. Acute respiratory distress syndrome is also a potential complication, but the risk of infection is greater because of the loss of the skin barrier. Catecholamine release and gastrointestinal ischemia are the causes of stress ulcers.
Question 3 of 5
A patient with cancer is experiencing hair loss from chemotherapy treatments. Which term should the nurse use to document this finding?
Correct Answer: A
Rationale: Hair loss is called alopecia. Allopathy is a system of medicine. Ecchymosis is bruising. Keratopenia is not a medical term.
Question 4 of 5
The nurse notes that an older patient is malnourished and has minimal subcutaneous tissue. Which function of the subcutaneous tissue of the skin should the nurse consider as being potentially altered in this patient?
Correct Answer: A
Rationale: Subcutaneous tissue stores energy as fat, which is compromised in malnutrition.
Question 5 of 5
Which of the following is the most appropriate nursing intervention to facilitate healing in a patient who has suffered a hip fracture?
Correct Answer: B
Rationale: Placing a pillow between the patient's legs when turning prevents adduction and supports the patient's legs. Administering analgesics addresses pain but does not directly protect bone remodeling and promote healing. Rotation of the affected leg can cause dislocation and must be avoided. Prone positioning does not need to be maintained at all times.