Integumentary System NCLEX Questions
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Question 1 of 5.
The experienced nurse is observing the new nurse administer medications. Which actions by the new nurse require the experienced nurse to intervene? Select all that apply.
A. Applies tretinoin to an open wound on the face of the client with acne
B. Withholds isotretinoin until the client's pregnancy status is known
C. Withholds fluorouracil because the client's papules of actinic keratosis are worse
D. Waits two hours after the client bathes and uses lotion to apply tacrolimus
E. Tells the client taking acitretin for psoriasis to prevent pregnancy for a year
Explanation: Tretinoin (Retin-A) should not be applied to open wounds; the experienced nurse should intervene. Actinic keratosis treatment using fluorouracil (Carac) causes the affected area to become worse before getting better; the medication should not be withheld. When taking acitretin (Soriatane), the client should not become pregnant for three years following treatment. Withholding isotretinoin until pregnancy status is known is appropriate. Waiting two hours to apply tacrolimus after lotion is correct.
Question 2 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?
A. Replace fluids and electrolytes.
B. Prevent contractures of extremities.
C. Monitor urine output hourly.
D. Prepare to assist with an escharotomy.
Explanation: 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 3 of 5.
The nurse is caring for a client with deep partial-thickness and full-thickness burns to the chest area. Which assessment data would warrant notifying the health-care provider?
A. The client is complaining of severe pain.
B. The client's pulse oximeter reading is 95%.
C. The client has T 100.4°F, P 100, R 24, and BP 102/60.
D. The client's urinary output is 50 mL in two (2) hours.
Explanation: Fever, tachycardia, and hypotension suggest sepsis or hypovolemia, requiring immediate HCP notification. Pain is expected, 95% SpO2 is acceptable, and low urine output is secondary.
Question 4 of 5.
The nurse is caring for clients in a long-term care facility. Which is a modifiable risk factor for the development of pressure ulcers?
A. Constant perineal moisture.
B. Ability of the clients to reposition themselves.
C. Decreased elasticity of the skin.
D. Impaired cardiovascular perfusion of the periphery.
Explanation: Perineal moisture is modifiable through hygiene and barriers, reducing ulcer risk. Repositioning ability, skin elasticity, and perfusion are less modifiable.
Question 5 of 5.
The nurse is developing a plan of care for a client diagnosed with left-sided paralysis secondary to a right-sided cerebrovascular accident (stroke). Which should be included in the interventions?
A. Use a pillow to keep the heels off the bed when supine.
B. Order a low air-loss therapy bed immediately.
C. Prepare to insert a nasogastric feeding tube.
D. Order an occupational therapy consult for strength training.
Explanation: Heel elevation prevents pressure ulcers in paralyzed clients. Low air-loss beds require HCP orders, NG tubes are premature, and OT is for rehabilitation, not immediate care.