ATI RN
NCLEX Practice Questions Skin Integrity and Wound Care Questions
Question 1 of 5
The nurse is providing discharge instructions to a client recovering from cellulitis. Which client statement indicates that this teaching has been effective?
Correct Answer: A
Rationale: The correct answer is A because it demonstrates understanding of the importance of monitoring for signs of infection after cellulitis. Fever, chills, malaise, redness, or tenderness at the site are all indicative of infection worsening. This client statement shows awareness of the need for ongoing vigilance. Choice B is incorrect because stopping antibiotics prematurely can lead to antibiotic resistance and recurrence of infection. Choice C is incorrect because squeezing pustules can introduce further infection or worsen the condition. Choice D is incorrect because drainage from the site may indicate ongoing infection and should be monitored closely.
Question 2 of 5
Necrosis of respiratory epithelial cells and shedding of serous and ciliated cells of the respiratory tract produce which common symptom of influenza?
Correct Answer: D
Rationale: The shedding of serous and ciliated cells in the respiratory tract leads to rhinorrhea, which is a common symptom of influenza. This process causes an increase in nasal secretions and results in a runny nose. Malaise (A) is a general feeling of discomfort, not directly related to shedding of respiratory cells. Coryza (B) refers to nasal congestion, not shedding of cells. Cough (C) is more commonly associated with irritation of the respiratory tract, not shedding of cells. Therefore, D is the correct answer.
Question 3 of 5
The nurse correctly explains to a young mother that bottle-feeding an infant in the upright position may help to prevent which infectious health problem?
Correct Answer: D
Rationale: The correct answer is D: Otitis media. Bottle-feeding in an upright position helps prevent fluid from entering the middle ear, reducing the risk of otitis media. This infection occurs when bacteria from the nose and throat travel through the Eustachian tube to the middle ear. By keeping the infant upright during feeding, gravity helps prevent this bacterial migration. Choices A, B, and C are incorrect as bottle-feeding in an upright position does not directly impact choking, aspiration, or sinus infections.
Question 4 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 5 of 5
The nurse is providing teaching on preventing sepsis. Which should the nurse include as a major risk factor for the development of this health problem?
Correct Answer: C
Rationale: The correct answer is C: Undiagnosed urinary tract infection. UTI is a major risk factor for sepsis as it can lead to bacterial infection spreading to the bloodstream. This can result in systemic inflammation and organ dysfunction, which are characteristic of sepsis. Pneumococcal bacteria (choice A) and leukocytosis (choice B) are not risk factors but rather potential indicators of infection. Elevated temperature (choice D) may indicate infection, but it is not a specific risk factor for sepsis like an untreated UTI.