Integumentary Disorders NCLEX Questions
Home / Nursing & Allied Health Certifications / NCLEX PN / Integumentary
Question 1 of 5.
The client experiences local burning and stinging when mafenide cream is applied to treat a burn injury. Which action should be taken by the nurse?
A. Remove any mafenide that has been applied.
B. Immediately notify the health care provider.
C. Double-check the concentration of mafenide.
D. Inform the client that this is a normal response.
Explanation: Burning or stinging with application of mafenide (Sulfamylon) is a normal response. Mafenide is bacteriostatic and used to reduce gram-negative and gram-positive organisms present in burned tissues. Removal of mafenide or notifying the HCP is unnecessary. Mafenide cream is supplied in 11.2% cream; there are no other concentrations available.
Question 2 of 5.
The client comes into the emergency department in severe pain and reports that a pot of boiling hot water accidentally spilled on his lower legs. The assessment reveals blistered, mottled red skin, and both feet are edematous. Which depth of burn should the nurse document?
A. Superficial partial thickness.
B. Deep partial thickness.
C. Full thickness.
D. First degree.
Explanation: Blistered, mottled red skin with edema indicates deep partial-thickness burns, affecting the dermis with severe pain. Superficial partial thickness has no blisters, full thickness is painless and leathery, and first degree is superficial with erythema.
Question 3 of 5.
The nurse writes the nursing diagnosis 'impaired skin integrity related to open burn wounds.' Which intervention would be appropriate for this nursing diagnosis?
A. Provide analgesia before pain becomes severe.
B. Clean the client's wounds, body, and hair daily.
C. Screen visitors for respiratory infections.
D. Encourage visitors to bring plants and flowers.
Explanation: Daily wound cleaning prevents infection and promotes healing, addressing impaired skin integrity. Analgesia addresses pain, visitor screening is for infection control, and plants increase infection risk.
Question 4 of 5.
The nurse in a long-term care facility is teaching a group of new unlicensed assistive personnel. Which information regarding skin care should the nurse emphasize?
A. Keep the skin moist by leaving the skin damp after the bath.
B. Do not rub any lotion into the skin.
C. Turn clients who are immobile at least every two (2) hours.
D. Only the licensed nursing staff may care for the client's skin.
Explanation: Turning every 2 hours prevents pressure ulcers by relieving pressure. Damp skin risks breakdown, lotion is beneficial, and UAPs can assist with skin care.
Question 5 of 5.
The nurse and an unlicensed assistive personnel (UAP) on a medical floor are caring for clients who are elderly and immobile. Which action by the UAP warrants immediate intervention by the nurse?
A. The UAP elevates the head of the bed of a client who can feed himself with minimal assistance.
B. The UAP asks to take a meal break before turning the clients at the two (2)-hour time limit.
C. The UAP restocks the rooms that need unsterile gloves before clocking out for the shift.
D. The UAP mixes Thick-It into the glass of water for a client who has difficulty swallowing.
Explanation: Delaying turning immobile clients risks pressure ulcers, requiring immediate intervention. Bed elevation, restocking, and Thick-It are appropriate.
Related Questions