NCLEX-PN
Integumentary Disorders NCLEX Questions Questions
Extract:
Question 1 of 5
The nurse and an unlicensed assistive personnel (UAP) are caring for a client with a stage IV pressure ulcer. Which action by the UAP warrants intervention by the nurse?
Correct Answer: D
Rationale: Multiple diapers increase moisture and pressure, worsening stage IV ulcers. Turning, wrinkle-free sheets, and protein drinks are appropriate.
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
Which question is most appropriate for the nurse to ask at this time?
Correct Answer: D
Rationale: Excessive aspirin use can cause tinnitus, making it the most relevant question.
Question 4 of 5
Which nursing intervention is most appropriate to include in the care plan of an anxious client who is blind or has the eyes patched?
Correct Answer: B
Rationale: Explaining actions beforehand reduces anxiety by preparing the client for what to expect.
Question 5 of 5
The client with thick, crusty, yellow toenails is diagnosed with tinea unguium (onychomycosis) and asks the clinic nurse what happens if he can’t afford to take the medication the physician prescribed. The nurse’s response will be based on which scientific rationale?
Correct Answer: C
Rationale: Untreated onychomycosis can destroy the toenail plate, causing separation. Gangrene is unlikely, OTC creams are less effective, and antibiotics are irrelevant.