ATI RN
NCLEX Questions on Skin Integrity and Wound Care Questions
Question 1 of 5
The nurse is providing discharge teaching to a client recovering from pneumonia. Which client statement indicates that additional teaching is needed?
Correct Answer: C
Rationale: Rationale: C is correct because the pneumococcal vaccine is not given every fall; it's typically recommended once or in some cases, a booster after a certain period. A is incorrect as alternative vaccines are available for those allergic to eggs. B is a good practice as the influenza vaccine should be received annually. D is incorrect because the pneumococcal vaccine primarily protects against pneumococcal disease, not all bacterial pneumonia.
Question 2 of 5
An adolescent client is brought to the emergency department (ED) with fatigue, weight loss, a dry cough, and night sweats. The family just recently immigrated to the United States. Based on this data, which potential risk should the nurse include when planning care for this client?
Correct Answer: A
Rationale: The correct answer is A: Pneumothorax. Given the symptoms of fatigue, weight loss, dry cough, and night sweats in an adolescent who recently immigrated, the nurse should consider tuberculosis (TB) as a potential risk. TB can lead to pneumothorax due to lung cavitation and can present with the symptoms described. Atelectasis, renal failure, and reduced peristalsis are less likely in this scenario and do not align with the client's presenting symptoms and recent immigration history.
Question 3 of 5
The most common type of upper urinary tract infection that results from bacteria ascending to the kidney from the lower respiratory tract is
Correct Answer: C
Rationale: The correct answer is C: pyelonephritis. This is because pyelonephritis is a type of upper urinary tract infection that occurs when bacteria ascends from the lower urinary tract to the kidney, often through the ureters. Urethritis (choice A) is an infection of the urethra, not the kidney. Prostatitis (choice B) is an infection of the prostate gland, not the kidney. Cystitis (choice D) is a lower urinary tract infection involving the bladder, not the kidney. Therefore, pyelonephritis is the most appropriate choice in this scenario.
Question 4 of 5
A client with a previously healed tuberculosis lesion experiences lesion rupture that leads to active disease. Which type of tuberculosis does this client have?
Correct Answer: C
Rationale: Rationale: 1. The client had a previously healed lesion, indicating latent infection. 2. Rupture led to active disease, suggesting reactivation of latent infection. 3. Therefore, the client has reactivation tuberculosis. Summary: - A: Miliary TB is widespread dissemination, not related to a single lesion. - B: Extrapulmonary TB affects organs other than the lungs. - D: Cavitation TB involves formation of cavities in the lungs, not directly related to lesion rupture.
Question 5 of 5
The nurse prepares to obtain a culture from a patient who has a possible fungal infection on the foot. Which items should the nurse gather for this procedure?
Correct Answer: A
Rationale: The correct answer is A: Sterile gloves. When obtaining a culture for a fungal infection, sterile gloves are essential to prevent contamination. The nurse needs to maintain aseptic technique to ensure accurate results and prevent potential spread of infection. Patch test instruments (B) are used for allergy testing, not for obtaining cultures. Cotton-tipped applicators (C) are usually used for wound care or specimen collection, but not ideal for obtaining fungal cultures. Syringe and intradermal needle (D) are typically used for administering medications or taking blood samples, not for fungal culture collection.