Med Surg Integumentary NCLEX Questions
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Question 1 of 5.
The nurse suspects that the client's anxiety is due to fear that nursing care will intensify symptoms. Which nursing intervention is most appropriate to add to the care plan?
A. Let the client suggest ways to carry out care.
B. Discontinue nursing care measures at this time.
C. Restrict care to nutrition and elimination only.
D. Carry out nursing activities quickly and efficiently.
Explanation: Involving the client in care decisions reduces anxiety by providing control.
Question 2 of 5.
The client is scheduled to have a xenograft to a left lower-leg burn. The client asks the nurse, 'What is a xenograft?' Which statement by the nurse would be the best response?
A. The doctor will graft skin from your back to your leg.'
B. The skin from a donor will be used to cover your burn.'
C. The graft will come from an animal, probably a pig.'
D. I think you should ask your doctor about the graft.'
Explanation: A xenograft uses animal skin (e.g., porcine) for temporary burn coverage. Autografts use the patient's skin, allografts use donor human skin, and deferring to the doctor avoids education.
Question 3 of 5.
The client sustained a hot grease burn to the right hand and calls the emergency department for advice. Which information should the nurse provide to the client?
A. Apply an ice pack to the right hand.
B. Place the hand in cool water.
C. Be sure to rupture any blister formation.
D. Go immediately to the doctor's office.
Explanation: Cool water reduces burn progression and pain without tissue damage. Ice causes frostbite, rupturing blisters risks infection, and immediate doctor visits depend on severity.
Question 4 of 5.
The paraplegic client is being admitted to a medical unit from home with a stage IV pressure ulcer over the right ischium. Which assessment tool should be completed on admission to the hospital?
A. Complete the Braden Scale.
B. Monitor the client on a Glasgow Coma Scale.
C. Assess for Babinski's sign.
D. Initiate a Brudzinski flow sheet.
Explanation: The Braden Scale assesses pressure ulcer risk, guiding interventions. Glasgow, Babinski, and Brudzinski are neurological, not relevant to ulcers.
Question 5 of 5.
The nurse writes the problem 'impaired skin integrity' for a client with stage IV pressure ulcers. Which interventions should be included in the plan of care? Select all that apply.
A. Turn the client every three (3) to four (4) hours.
B. Ask the dietitian to consult.
C. Have the client sign a consent for pictures of the wounds.
D. Obtain an order for a low air-loss bed.
E. Elevate the head of the bed at all times.
Explanation: Dietitian consult, wound photos (with consent), and low air-loss bed address stage IV ulcers. Turning every 3–4 hours is too infrequent, and constant head elevation increases coccyx pressure.
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