NCLEX-PN
NCLEX Questions Integumentary System Questions
Extract:
Question 1 of 5
The nurse is caring for the client with a burn injury. Which findings should prompt the nurse to notify the HCP because the client may be developing sepsis?
Correct Answer: C
Rationale: T 103.2°F (39.6°
C) and HR 120 bpm may indicate that the client has sepsis. A Paco2 35 mm Hg is WNL. Hyperglycemia does occur in sepsis, but this alone is not sufficient. Abnormal clotting may occur with sepsis, but hypoglycemia does not. An RR of 34 breaths/min may indicate sepsis, but the WBC is WNL.
Question 2 of 5
An electrician was wearing a glove that had a hole in it when he grabbed a 'hot' wire. His coworkers came to him immediately and called the rescue squad. When the industrial nurse reached him, the electric current had been shut off. What action should the nurse take initially?
Correct Answer: B
Rationale: Checking respirations and pulse rate is the initial action to assess for life-threatening complications, such as cardiac arrhythmias, common in electrical burns.
Question 3 of 5
Which finding of the client's biographical data most likely contributed to developing skin cancer?
Correct Answer: B
Rationale: Baldness increases scalp sun exposure, a risk factor for skin cancer.
Question 4 of 5
The nurse is caring for clients with second- and third-degree burns. Which medication should the nurse plan to apply topically to treat bacterial and yeast infections?
Correct Answer: C
Rationale: Silver sulfadiazine (Silvadene) is a topical anti-infective agent for prevention and treatment of wound infection in second- and third-degree burn clients. Bismuth subsalicylate (Kaopectate) is an antidiarrheal medication. Gold sodium thiomalate (Aurolate) is used to treat rheumatoid arthritis resistant to conventional therapy. Arsenic trioxide (Trisenox) is an antineoplastic.
Question 5 of 5
The wound care nurse documented a client’s pressure ulcers on admission as 3.3 cm × 4 cm stage II on the coccyx. Which information would alert the nurse that the client’s pressure ulcer is getting worse?
Correct Answer: D
Rationale: Extension to the subcutaneous layer with drainage indicates progression to stage III or IV, worsening the ulcer. Smaller size, blisters, or pain are less severe.