Integumentary NCLEX RN Questions
Question 1 of 5.
The nurse is immediately concerned that the client is at risk for developing …………….. as evidenced by the client's ………………
A. carbon monoxide poisoning
B. wound infection
C. cardiac dysrhythmias
D. Glasgow Coma Scale
E. pulse
F. pain level
Explanation: The client's report of feeling like his 'heart is intermittently skipping' indicates a potential cardiac dysrhythmia, which is a serious complication of electrical burns due to the effect of electrical current on the heart. The pulse is the finding that supports this concern.
Question 2 of 5.
A nurse is taking care of a client with severe burns. Which of the following is the best intervention to prevent shock in this client?
A. Administer dopamine as ordered
B. Apply medical anti-shock trousers
C. Infuse IV fluids as indicated
D. Infuse fresh frozen plasma
Explanation: Infusing IV fluids is the best intervention to prevent hypovolemic shock in burn patients by restoring circulating volume lost due to fluid shifts from severe burns.
Question 3 of 5.
The ABCDEs of melanoma identification include which of the following? Select all that apply.
A. Asymmetry: one half does not match the other half
B. Birthmark: cafe au lait spot that does not fade
C. Color: pigmentation is not uniform
D. Diameter: greater than 6 mm
E. Evolving: any change in size, shape, color, elevation, or any new symptom such as bleeding, itching, or crusting
Explanation: The ABCDEs of melanoma are Asymmetry, Border (irregular), Color (varied), Diameter (>6 mm), and Evolving (changes in appearance or symptoms). Birthmark is not part of this mnemonic.
Question 4 of 5.
The nurse is conducting a community health class on skin changes for older adults. It would be appropriate for the nurse to state which of the following are normal age-related changes? Select all that apply.
A. Decreased dermal blood flow
B. Development of actinic lentigo
C. Degeneration of elastic fibers
D. Loss of subcutaneous fat
E. Increased epidermal thickness
Explanation: Normal age-related skin changes include decreased dermal blood flow, actinic lentigo (age spots), degeneration of elastic fibers (leading to wrinkles), and loss of subcutaneous fat (thinner skin). Increased epidermal thickness is not typical; the epidermis thins with age.
Question 5 of 5.
The nurse is caring for a client with several severe pressure ulcers. Which laboratory result requires the nurse to intervene?
A. Serum albumin level of 2.5 g/dL [3.5-5 g/dL]
B. Serum potassium level of 4 mEq/L (mmol/L) [3.5 and 5.0 mEq/L (mmol/L)]
C. Serum sodium level of 140 mEq/L (mmol/L) [135-145 mEq/L (mmol/L)]
D. White blood cell count of 9,000 cells/uL (9x10%) [4,500-11,000 cells/uL, 3.5-10.5 × 10°/L]
Explanation: A low serum albumin level (2.5 g/dL) indicates malnutrition, which impairs wound healing and requires intervention. Other lab values are within normal ranges.
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