Which of the following would the nurse recognize as an accurate statem

Integumentary Disorders NCLEX RN Questions

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Question 1 of 5.

Which of the following would the nurse recognize as an accurate statement regarding pressure ulcers? Select all that apply.

A. In a stage Il pressure ulcer, part of the dermis and epidermis are lost.'

B. In a stage I pressure ulcer, there is a loss of integrity of the epidermis only.'

C. In a stage Ill pressure ulcer, a deep tissue injury can expose fat.'

D. In a stage IV pressure ulcer, the base of the wound is covered by eschar.'

E. Stage Ill involves extensive tissue damage and can lead to bone and muscle involvement.'

Explanation: Stage II involves partial loss of dermis and epidermis, and Stage III can expose fat. Stage I is non-blanchable redness, Stage IV may expose bone/muscle, and eschar is not always present.

Question 2 of 5.

A nurse is caring for a client at risk of developing pressure ulcers. Which of the following is an intrinsic risk factor that contributes to this increased risk?

A. Shearing

B. Friction

C. Impaired tissue perfusion

D. Pressure

Explanation: Impaired tissue perfusion is an intrinsic risk factor because it originates within the body, affecting blood flow and tissue oxygenation, which can lead to pressure ulcer development. Shearing, friction, and pressure are extrinsic factors as they are external forces acting on the skin.

Question 3 of 5.

The nurse recognizes that rewarming a client with hypothermia must be done slowly to prevent

A. Superficial burns

B. ventricular fibrillation

C. frostbite

D. muscle spasms

Explanation: Rapid rewarming can cause ventricular fibrillation due to sudden changes in core temperature affecting cardiac rhythm. Slow rewarming helps stabilize the cardiovascular system.

Question 4 of 5.

Which of the following interventions by the newly hired nurse requires follow-up? Select all that apply.

A. Applies zinc oxide to the client's perineal skin

B. Provides a donut pillow while the client is sitting in the chair

C. Maintain the head of the client's bed at 90 degrees

D. Encourages the client to consume foods rich in carbohydrates

E. Uses a pillow to float the client's heels

Explanation: Donut pillows can increase pressure on surrounding tissues, worsening ulcer risk. Maintaining the head of the bed at 90 degrees increases shearing forces, promoting ulcer development. Zinc oxide, high-protein diets (not just carbohydrates), and floating heels are appropriate interventions.

Question 5 of 5.

The nurse is conducting a staff in-service on managing an acute burn. The nurse should reinforce the utilization of which formula to guide fluid resuscitation?

A. 4 mL x kg x Total Body Surface Area (TBSA) burned

B. 30 mL/kg

C. 0.5 mL/kg/hr

D. 0.10 mL/kg/hr

Explanation: The Parkland formula (4 mL x kg x TBSA burned) is used to calculate fluid resuscitation needs in burn patients to restore circulating volume.