ATI RN
Skin Integrity and Wound Care NCLEX Questions Questions
Question 1 of 5
Upon learning that Aaron has a pressure-reducing gel chair cushion for his wheelchair, which action should the nurse take?
Correct Answer: A
Rationale: The correct answer is A because a pressure-reducing gel chair cushion helps prevent pressure ulcers in individuals who use wheelchairs. Encouraging Aaron to continue using this device is crucial for maintaining skin integrity and preventing skin breakdown. Option B is incorrect as a donut-shaped foam cushion may not provide the same level of pressure relief. Option C is incorrect as avoiding pressure cushions can increase the risk of pressure ulcers. Option D is incorrect as regular skin moisturizer alone cannot provide the necessary pressure relief that a cushion can offer.
Question 2 of 5
The nurse is caring for a client who is exhibiting signs of a systemic infection following surgery. Which diagnostic tests would the nurse anticipate being ordered? Select the one that does not apply
Correct Answer: A
Rationale: The correct answer is A: Serum electrolyte levels. In a client exhibiting signs of systemic infection, diagnostic tests typically include white blood cell differential and count to assess for infection. Urinalysis may reveal signs of infection in the urinary system. Serum electrolyte levels are not directly related to diagnosing systemic infection and would not be a priority in this scenario. Monitoring electrolyte levels is important for other conditions like dehydration or kidney disease.
Question 3 of 5
The nurse is caring for a client with gangrene of the toe. Which collaborative intervention should the nurse anticipate preparing the client for?
Correct Answer: A
Rationale: The correct answer is A: Surgery. In the case of gangrene of the toe, surgical intervention is often necessary to remove the dead tissue and prevent further spread of infection. Surgery can involve amputation of the affected toe or foot to save the client's life and prevent complications. Debridement (choice B) is a related procedure but may not be sufficient in severe cases of gangrene. Myringotomy (choice C) is a procedure to relieve pressure or drain fluid from the middle ear, not related to gangrene treatment. Wound irrigation (choice D) is a general wound care procedure and may not address the severity of gangrene effectively.
Question 4 of 5
The nurse is caring for a client who has been diagnosed with orbital cellulitis. Which assessment finding should the nurse anticipate?
Correct Answer: B
Rationale: The correct answer is B: Edema of the affected eye. Orbital cellulitis is characterized by inflammation and infection of the tissues surrounding the eye, leading to swelling and edema. This assessment finding is expected due to the inflammatory response. Sunken eyes (A) are not typically associated with orbital cellulitis. Increased acuity of the affected eye (C) is unlikely as the infection can impair vision. Elevated blood pressure (D) is not a typical assessment finding for orbital cellulitis.
Question 5 of 5
Which term is commonly used by clients to describe conjunctivitis?
Correct Answer: B
Rationale: The correct answer is B: Pink eye. Clients commonly use this term to describe conjunctivitis due to the characteristic pink or red appearance of the eye. Conjunctivitis is an inflammation of the conjunctiva, the thin membrane covering the white part of the eye. A stye (A) is a localized infection in an eyelash follicle, not the same as conjunctivitis. Red eye (C) is a general term for any redness in the eye, not specific to conjunctivitis. Retinitis (D) refers to inflammation of the retina, which is not the same as conjunctivitis.