ATI RN
NCLEX Questions on Skin Integrity and Wound Care Questions
Question 1 of 5
When providing care to a client with a wound, which evidence-based interventions should the nurse anticipate carrying out? Select the one that does not apply
Correct Answer: B
Rationale: The correct answer is B. Covering the wound only if a scab forms is not an evidence-based intervention because it can interfere with the natural healing process. Keeping the wound dry (A) helps prevent infection. Ensuring the wound remains moist (C) promotes healing. Keeping the wound covered (D) provides protection and maintains a moist environment. In summary, B is incorrect because covering the wound based on scab formation does not align with best practices for wound care.
Question 2 of 5
Because of the way the influenza virus is transmitted from person to person, nurses who are working with clients with influenza should implement
Correct Answer: A
Rationale: The correct answer is A: droplet precautions. Influenza virus is primarily transmitted through respiratory droplets when an infected person coughs or sneezes. Droplet precautions involve wearing a mask and eye protection to prevent the spread of droplets. Isolation precautions (B) are used for infections spread by contact with the patient or their environment. Airborne precautions (C) are for infections transmitted through small particles that remain suspended in the air. Contact precautions (D) are for infections spread by direct or indirect contact with the patient or their environment. Droplet precautions are the most appropriate for influenza due to its mode of transmission through respiratory droplets.
Question 3 of 5
A client has completed the full course of antibiotics prescribed to treat otitis media. Which primary manifestation of the disorder will be relieved as evidence that treatment has been effective?
Correct Answer: C
Rationale: The correct answer is C: Pain. Effective treatment of otitis media should result in the relief of pain, which is a primary manifestation of the disorder. Antibiotics target the infection causing the inflammation and pain in the ear. Impaired hearing (A) may persist even after the infection is treated, as inflammation can take time to resolve. Dizziness (B) may be a symptom of inner ear involvement but is not the primary manifestation of otitis media. Nausea and vomiting (D) are not typically associated with otitis media and would not be relieved by completing the course of antibiotics.
Question 4 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 5 of 5
A 1-month-old infant is admitted to the hospital with a temperature of 102°F. What is the rationale for a complete septic workup?
Correct Answer: B
Rationale: The correct answer is B: Immature immune system. A 1-month-old infant has an underdeveloped immune system, making them more susceptible to infections. A temperature of 102°F suggests a potential serious infection like sepsis. A complete septic workup is necessary to identify the source of infection and initiate appropriate treatment promptly. Choices A, C, and D are incorrect because the absence of sweat glands, inadequate red blood cells, and poor lung elasticity do not directly relate to the need for a septic workup in this scenario.