Integumentary System NCLEX Questions
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Question 1 of 5.
When assessing the client's skin the nurse notices a rounded area of hair loss with redness, pustules, and scales that appear greenish-yellow when exposed to a black light (Wood's lamp). The nurse should plan to implement treatment for which condition?
A. Lyme disease
B. Fungal infection
C. Anaerobic infection
D. Contact dermatitis
Explanation: A fungal infection that manifests on the scalp with red, scaly lesions and hair loss will appear either greenish-yellow or bluish-green under a Wood's lamp. Lyme disease produces a bull's-eye rash that does not fluoresce. Anaerobic infections have diffuse redness and do not fluoresce. Contact dermatitis does not display a discrete, rounded area of hair loss or fluoresce.
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.