NCLEX-PN
Integumentary System NCLEX Questions Questions
Extract:
Question 1 of 5
The nurse is planning care for the client with a Stage II pressure ulcer on the ball of the right foot. Which interventions should the nurse include in this client's care? Select all that apply.
Correct Answer: C,D,E
Rationale: The dressing protects the underlying wound and provides a moist environment for healing. The client should be repositioned at least every 2 hours. Positioning devices are utilized to keep the load or pressure off the wound. Daily wound cultures are unnecessary, as all wounds contain bacteria. The wound should be cleansed gently to prevent further tissue trauma.
Question 2 of 5
The ED nurse is caring for a client admitted with extensive, deep partial-thickness and full-thickness burns. Which interventions should the nurse implement? List in order of priority.
Order the Items
Source Container
Correct Answer: D,B,E,A,C
Rationale: Priority: 1) Airway status (ABCs); 2) IV catheters/fluids (prevent shock); 3) Morphine (pain control); 4) Rule of nines (guide resuscitation); 5) Sterile dressings (infection prevention).
Question 3 of 5
The client has full-thickness burns to 65% of the body, including the chest area. After establishing a patent airway, which collaborative intervention is priority for the client?
Correct Answer: A
Rationale: Massive fluid loss in 65% burns requires immediate fluid and electrolyte replacement to prevent shock. Contracture prevention, urine monitoring, and escharotomy are secondary after fluid resuscitation.
Question 4 of 5
If a client with a middle ear infection reports the following symptoms, the blood pressure and the infection has spread to the inner ear?
Correct Answer: D
Rationale: Postural dizziness suggests inner ear involvement, such as labyrinthitis.
Question 5 of 5
If a client who has recently experienced diminished hearing takes medications from each of the following drug categories, which one is most likely to have affected the client's hearing?
Correct Answer: C
Rationale: Aminoglycosides are ototoxic and can cause hearing loss.