Integumentary NCLEX Questions
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Question 1 of 5.
What is the best evidence that the antibiotic the nurse is administering for the treatment of acute otitis media is having a therapeutic effect?
A. The ear feels less warm to the touch.
B. Ear drainage is thin and watery.
C. Ear discomfort is relieved.
Explanation: Relief of ear discomfort indicates the infection is responding to treatment.
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.
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