ATI RN
Skin Integrity and Wound Care NCLEX Questions Questions
Question 1 of 5
What should the nurse recommend for a pregnant client who is concerned about a recent flu outbreak?
Correct Answer: A
Rationale: The correct answer is A. The nurse should recommend that the client receive the influenza vaccination because it is safe during pregnancy and helps protect both the mother and the baby from potential complications of the flu. Vaccination is the most effective way to prevent flu infection. Choice B is incorrect because staying home does not provide the same level of protection as vaccination. Choice C is incorrect as amantadine is not recommended during pregnancy due to potential risks to the fetus. Choice D is incorrect as while a healthy diet is important, it is not sufficient to protect against the flu during pregnancy.
Question 2 of 5
The nurse is caring for a client who develops a fever and productive cough after abdominal surgery. Which orders should the nurse expect from the healthcare provider? Select all that apply.
Correct Answer: C
Rationale: The correct answer is C: Chest physiotherapy. After abdominal surgery, the client is at risk for developing atelectasis due to shallow breathing and ineffective coughing. Chest physiotherapy helps improve lung expansion and secretion clearance, preventing complications like pneumonia. Sputum cultures (A) and bronchial washing for culture (D) are not typically indicated in this scenario unless there are specific indications such as suspected infection. Antibiotics (B) should not be given prophylactically without evidence of infection. In summary, chest physiotherapy is essential for preventing respiratory complications post-abdominal surgery, while the other options are not necessary unless there are specific indications.
Question 3 of 5
The nurse is caring for an older adult client who developed sepsis from a pressure ulcer while residing in a long-term care facility. The family asks how they can help prevent this from happening again in the future. Which response by the nurse is best?
Correct Answer: D
Rationale: Correct Answer: D. Assist the client with meals to obtain optimal nourishment. Rationale: 1. Optimal nourishment is crucial for the client's immune system to fight off infection. 2. Malnutrition can weaken the body's ability to heal and recover. 3. Adequate nutrition is essential for tissue repair and prevention of pressure ulcers. Summary: A: Alerting the staff about the IV is important but not directly related to preventing pressure ulcers. B: Helping with dressing changes is beneficial, but nutrition plays a more significant role in preventing sepsis. C: Assisting the client to the bathroom is important for fall prevention but does not directly address the underlying cause of sepsis from pressure ulcers.
Question 4 of 5
The nurse is planning care for a client recently diagnosed with tuberculosis (TB). The client lives alone in an apartment and will continue treatment at home. When reviewing the client's history, the nurse notes that the client has had trouble complying with medication regimens in the past. Which nursing diagnosis is a priority for this client?
Correct Answer: A
Rationale: The correct answer is A: Ineffective Health Management. This is because the client's history of noncompliance with medication regimens indicates a potential risk for ineffective management of their health. This diagnosis is a priority as ensuring adherence to TB treatment is crucial for the client's health and preventing the spread of the disease. Choice B: Deficient Knowledge may not be the priority as the client's issue seems to be related to compliance rather than lack of knowledge. Choice C: Ineffective Breathing Pattern and Choice D: Risk for Injury are not as directly related to the client's history of medication noncompliance. The priority is to address the client's difficulty in managing their health effectively.
Question 5 of 5
A mother brings in her 6-year-old daughter with signs and symptoms of fever, reduced voiding, uncontrolled voiding, and pain during urination. The daughter is diagnosed with a urinary tract infection. Which nursing outcome is most appropriate for this client?
Correct Answer: B
Rationale: The correct answer is B: The client will report no episodes of enuresis. Enuresis refers to involuntary urination, which can be a common symptom of urinary tract infection in children. Achieving no episodes of enuresis indicates successful treatment and resolution of the infection. This outcome specifically addresses the client's urinary symptoms, making it the most appropriate choice. Choice A is incorrect as it focuses on bilirubin levels, which are not directly related to urinary tract infection. Choice C is incorrect as remaining afebrile for 12 hours does not address the urinary symptoms. Choice D is incorrect as it only focuses on the volume of urine voided and does not address the resolution of the infection or the client's symptoms.