NCLEX-PN
Med Surg Integumentary NCLEX Questions Questions
Extract:
Question 1 of 5
Three days ago the client received circumferential, partial, and full-thickness burns to 30% total body surface area of the chest and abdomen. The nurse monitors the client for restricted breathing due to Which physiological response?
Correct Answer: A
Rationale: A layer of eschar or devitalized tissue commonly forms over partial- and full-thickness burns, which, when circumferential and when combined with increased fluid retention, can restrict circulation and lung expansion. Loss of tissue containing elastin and collagen does occur in partial- and full-thickness burns but would not be a source of constriction that would prevent lung expansion. Ischemia and hypoxia may be experienced in the alveoli due to inhalation burns; however, restricted breathing (a mechanical process) is more of a risk due to circumferential eschar formation. Although fluid overload is a possibility, it is not likely to restrict breathing unless it is combined with eschar formation.
Question 2 of 5
The paraplegic client is being admitted to a medical unit from home with a stage IV pressure ulcer over the right ischium. Which assessment tool should be completed on admission to the hospital?
Correct Answer: A
Rationale: The Braden Scale assesses pressure ulcer risk, guiding interventions. Glasgow, Babinski, and Brudzinski are neurological, not relevant to ulcers.
Question 3 of 5
Which immediate nursing interventions are appropriate for this client? Select all that apply.
Correct Answer: B,C,D,E,F
Rationale: Ice packs can worsen tissue damage; other interventions address fluid loss, infection, pain, and oxygenation.
Question 4 of 5
The female teacher comes to the school nurse’s office and shows the nurse a rash on her hands. The nurse tells the teacher she has probably contracted impetigo from one of the students. Which intervention should the nurse implement?
Correct Answer: A
Rationale: Impetigo requires HCP evaluation for antibiotics. Handwashing is preventive, vitamin E is ineffective, and spontaneous resolution is unlikely.
Question 5 of 5
Which statement would the nurse expect the client to report when looking at an object without wearing corrective glasses or contact lenses?
Correct Answer: B
Rationale: Astigmatism causes blurry or distorted vision due to irregular corneal curvature.