Integumentary System NCLEX Questions Quizlet
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Question 1 of 5.
The nurse is caring for the client who is diagnosed with a carbuncle. Which home measures should the nurse discuss? Select all that apply.
A. Leave the draining lesion open to the air so it dries.
B. Use strict hand washing to prevent cross-contamination.
C. Cover the mattress and pillows with plastic covers.
D. Apply ice to the affected area 20 minutes twice daily.
E. Wash all linens, towels, and clothing after each use.
F. Remove all throw rugs to prevent tripping or falls.
Explanation: Treatments for an infected lesion should include strict hand washing to prevent cross-contamination. Covering mattress and pillows with plastic covers and washing all linens, towels, and clothing after each use will prevent cross-contamination. Leaving the lesion open to air is not advised; a dressing is needed. Applying ice or removing throw rugs does not pertain to carbuncle treatment.
Question 2 of 5.
The nurse is applying mafenide acetate (Sulfamylon), a sulfa antibiotic cream, to a client's lower extremity burn. Which assessment data would require immediate attention by the nurse?
A. The client complains of pain when the medication is administered.
B. The client's potassium level is 3.9 mEq/L and sodium level is 137 mEq/L.
C. The client's ABGs are pH 7.34, PaO2 98, PaCO2 38, and HCO3 20.
D. The client is able to perform active range-of-motion exercises.
Explanation: ABGs showing low HCO3 (20) and pH 7.34 suggest metabolic acidosis, a serious mafenide side effect requiring immediate attention. Pain is expected, electrolytes are normal, and ROM is positive.
Question 3 of 5.
The client is admitted with full-thickness and partial-thickness burns to more than 30% of the body. The nurse is concerned with the client's nutritional status. Which intervention should the nurse implement?
A. Encourage the client's family to bring favorite foods.
B. Provide a low-fat, low-cholesterol diet for the client.
C. Monitor the client's weight weekly in the same clothes.
D. Make a referral to the hospital social worker.
Explanation: Favorite foods increase caloric intake, critical for hypermetabolic burn patients. Low-fat diets are inappropriate, weekly weights are insufficient, and social worker referral is unrelated.
Question 4 of 5.
What is the scientific rationale for placing lift pads under an immobile client?
A. The pads will absorb any urinary incontinence and contain stool.
B. The pads will prevent the client from being diaphoretic.
C. The pads will keep the staff from workplace injuries such as a pulled muscle.
D. The pads will help prevent friction shearing when repositioning the client.
Explanation: Lift pads reduce friction and shear during repositioning, preventing skin breakdown. Absorbent pads address incontinence, diaphoresis is unrelated, and staff safety is secondary.
Question 5 of 5.
The client who is debilitated and has developed multiple pressure ulcers complains to the nurse during a dressing change that he is 'tired of it all.' Which is the nurse's best therapeutic response?
A. These wounds can heal if we get enough protein into you.'
B. Are you tired of the treatments and needing to be cared for?'
C. Why would you say that? We are doing our best.'
D. Have you made out an advance directive to let the HCP know your wishes?'
Explanation: Reflecting the client's feelings encourages discussion, addressing emotional distress. Protein focus, defensiveness, or advance directives dismiss the client's emotions.