Integumentary NCLEX Questions
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Question 1 of 5.
The nurse is caring for the client with a split-thickness skin graft taken from the thigh to cover a burn on the back. Which intervention should the nurse expect to implement to help reduce the risk of infection at the donor and graft site?
A. Obtain serial wound cultures of the donor site.
B. Eliminate plants and flowers in the client's room.
C. Use clean technique for all wound care procedures.
D. Administer a continual low dosage of an IV antibiotic.
Explanation: Pseudomonas has been found in plants and flowers, which may be a source of wound infection. Wound cultures are used to confirm an infection but do not prevent one. Sterile technique, not clean technique, would eliminate additional sources of infection. Continual low-dosage antibiotic infusions would not be effective due to increased metabolism in burn clients.
Question 2 of 5.
The client with full-thickness burns to 40% of the body, including both legs, is being transferred from a community hospital to a burn center. Which measure should be instituted before the transfer?
A. A 22-gauge intravenous line with normal saline infusing.
B. Wounds covered with moist sterile dressings.
C. No intravenous pain medication.
D. Ensure adequate peripheral circulation to both feet.
Explanation: Ensuring peripheral circulation prevents ischemic complications during transfer. A 22-gauge IV is too small for major burns, moist dressings are inappropriate for full-thickness burns, and IV pain medication is needed.
Question 3 of 5.
Which nursing interventions should be included for the client who has full-thickness and deep partial-thickness burns to 50% of the body? Select all that apply.
A. Perform meticulous hand hygiene.
B. Use sterile gloves for wound care.
C. Wear gown and mask during procedures.
D. Change central lines once a week.
E. Administer antibiotics as prescribed.
Explanation: Hand hygiene, sterile gloves, gown/mask, and antibiotics prevent infection in extensive burns. Weekly central line changes are not standard; daily assessment is preferred.
Question 4 of 5.
The nurse is caring for a client who has developed stage IV pressure ulcers on the left trochanter and coccyx. Which collaborative problem has the highest priority?
A. Impaired cognition.
B. Altered nutrition.
C. Self-care deficit.
D. Altered coping.
Explanation: Altered nutrition is critical in stage IV ulcers to support wound healing. Cognition, self-care, and coping are secondary in advanced wounds.
Question 5 of 5.
The nurse is caring for clients on a medical unit. After the shift report, which client should the nurse assess first?
A. The 34-year-old client who is quadriplegic and cannot move his arms.
B. The elderly client diagnosed with a CVA who is weak on the right side.
C. The 78-year-old client with pressure ulcers who has a temperature of 102.3°F.
D. The young adult who is unhappy with the care that was provided last shift.
Explanation: Fever in a client with pressure ulcers suggests infection, requiring urgent assessment. Quadriplegia, weakness, and dissatisfaction are less acute.