NCLEX-PN
Integumentary Disorders NCLEX Questions Questions
Extract:
Question 1 of 5
After reviewing the medical orders, which of the following is essential for the nurse to assess preoperatively?
Correct Answer: B
Rationale: Assessing the last anticoagulant dose is critical to prevent bleeding during surgery.
Question 2 of 5
The nurse determines that the fluid status of the client with a second-degree burn is inadequate and immediately notifies the HCP. The client is 5 hours postburn and weighs 60 kg. Which findings prompted the nurse's action?
Correct Answer: C
Rationale: The client weighing 60 kg weighs 132 lb (1 kg = 2.2 lb). For the adult client weighing 132 lb, a pulse rate of 130 bpm (tachycardia) and a low urine output of 25 mL/hr are signs of inadequate circulating fluid volume. The MAP for a BP of 92/60 mm Hg is 70.7, indicating adequate perfusion. A pulse of 100 bpm is WNL. Respirations of 18 per minute and pulse of 60 bpm are both WNL. A pulse of 106 bpm could be elevated due to pain, and the temperature of 98.4°F (36.9°
C) is considered normal.
Question 3 of 5
The nurse is assessing the client's grafted wound following a skin graft. Which information provided during shift report should prompt the nurse to carefully assess if the client has a wound infection?
Correct Answer: C
Rationale: An elevated temperature could be a sign of an infection. Normal WBC is 4500 to 11,100 microL, so 9900 is WNL. Clean wounds have serosanguineous drainage. Decreased urine output can indicate dehydration or renal failure, not infection.
Question 4 of 5
Postoperatively, which of the following client concerns should be the nurse's highest priority?
Correct Answer: A
Rationale: Pain is a priority as it may indicate complications like infection or graft failure.
Question 5 of 5
After reviewing the medical orders, which of the following is essential for the nurse to assess preoperatively?
Correct Answer: B
Rationale: Assessing the last anticoagulant dose is critical to prevent bleeding during surgery.