Integumentary System NCLEX Questions
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Question 1 of 5.
While the nurse is assessing the client hospitalized with recurrent lower-extremity cellulitis, the client states, 'I have athlete's foot; do you want to check it?' The nurse concludes that this information is significant for what reason?
A. Cellulitis is commonly caused by a similar fungal infection.
B. Both infections should resolve with topical fungicide therapy.
C. Painful neuralgia can occur after the cellulitis infection has resolved.
D. The skin disruption with tinea pedis may be the cause of the cellulitis.
Explanation: Cellulitis is an infection with diffuse inflammation occurring in the tissue just under the skin. Chronic athlete's foot causes minute breaks in the skin, allowing bacteria on the skin to enter the tissue and cause the infectious process. Cellulitis is caused by a bacterial infection, not fungal. Cellulitis requires antibiotics, not fungicides. Neuralgia is associated with herpes zoster, not cellulitis.
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.