Integumentary System Disorders | NCLEX Quiz 171

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Integumentary System Disorders | NCLEX Quiz 171 - Quiz

All questions are shown, but the results will only be given after you’ve finished the quiz. You are given 1 minute per question, a total of 10 minutes in this quiz.


Questions and Answers
  • 1. 

    Nurse JV is performing wound care. Which of the following practices violates surgical asepsis?

    • A.

      Holding sterile objects above the waist

    • B.

      Considering a 1? edge around the sterile field as being contaminated

    • C.

      Pouring solution onto a sterile field cloth

    • D.

      Opening the outermost flap of a sterile package away from the body

    Correct Answer
    C. Pouring solution onto a sterile field cloth
    Explanation
    Pouring solution onto a sterile field cloth violates surgical asepsis because moisture penetrating the cloth can carry microorganisms to the sterile field via capillary action. The other options are practices that help ensure surgical asepsis.

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  • 2. 

    During the acute phase of a burn. the nurse in-charge should assess which of the following?

    • A.

      Client’s lifestyle

    • B.

      Alcohol use

    • C.

      Tobacco use

    • D.

      Circulatory status

    Correct Answer
    D. Circulatory status
    Explanation
    During the acute phase of a burn. the nurse should assess the client’s circulatory and respiratory status. vital signs. fluid intake and output. ability to move. bowel sounds. wounds. and mental status. Information about the client’s lifestyle and alcohol and tobacco use may be obtained later when the client’s condition has stabilized.

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  • 3. 

    Nurse Catherine is changing a dressing and providing wound care. Which activity should she perform first?

    • A.

      Assess the drainage in the dressing.

    • B.

      Slowly remove the soiled dressing

    • C.

      Wash hands thoroughly.

    • D.

      Put on latex gloves.

    Correct Answer
    C. Wash hands thoroughly.
    Explanation
    When caring for a client. the nurse must first wash her hands. Putting on gloves. removing the dressing. and observing the drainage are all parts of performing a dressing change after hand washing is completed.

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  • 4. 

    Nurse Melinda is caring for an elderly bedridden adult. To prevent pressure ulcers. which intervention should the nurse include in the plan of care?

    • A.

      Turn and reposition the client at least once every 8 hours.

    • B.

      Vigorously massage lotion into bony prominences.

    • C.

      Post a turning schedule at the client’s bedside.

    • D.

      Slide the client. rather than lifting. when turning.

    Correct Answer
    C. Post a turning schedule at the client’s bedside.
    Explanation
    A turning schedule with a signing sheet will help ensure that the client gets turned and. thus. help prevent pressure ulcers. Turning should occur every 1 to 2 hours — not every 8 hours — for clients who are in bed for prolonged periods. The nurse should apply lotion to keep the skin moist but should avoid vigorous massage. which could damage capillaries. When moving the client. the nurse should lift — rather than slide — the client to avoid shearing.

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  • 5. 

    Nurse Jody formulates a nursing diagnosis of Impaired physical mobility for a client with third-degree burns on the lower portions of both legs. To complete the nursing diagnosis statement. the nurse should add which “related-to” phrase?

    • A.

      Related to fat emboli

    • B.

      Related to infection

    • C.

      Related to femoral artery occlusion

    • D.

      Related to circumferential eschar

    Correct Answer
    D. Related to circumferential eschar
    Explanation
    As edema develops on circumferential burns. eschar forms a tight. constricting band. compromising circulation to the extremity distal to the circumferential site and impairing physical mobility. This client isn’t likely to develop fat emboli unless long bone or pelvic fractures are present. Infection doesn’t alter physical mobility. A client with burns on the lower portions of both legs isn’t likely to have femoral artery occlusion.

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  • 6. 

    The nurse is assessing for the presence of cyanosis in a male dark-skinned client. The nurse understands that which body area would provide the best assessment?

    • A.

      Lips

    • B.

      Sacrum

    • C.

      Earlobes

    • D.

      Back of the hands

    Correct Answer
    A. Lips
    Explanation
    In a dark-skinned client. the nurse examines the lips. tongue. nail beds. conjunctivae. and palms of the hands and soles of the feet at regular intervals for subtle color changes. In a client with cyanosis. the lips and tongue are gray; the palms. soles. conjunctivae. and nail beds have a bluish tinge.

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  • 7. 

    Which of the following individuals is least likely to be at risk of developing psoriasis?

    • A.

      A 32 year-old-African American

    • B.

      A woman experiencing menopause

    • C.

      A client with a family history of the disorder

    • D.

      An individual who has experienced a significant amount of emotional distress

    Correct Answer
    A. A 32 year-old-African American
    Explanation
    Psoriasis occurs equally among women and men. although the incidence is lower in darker skinned races and ethnic groups. A genetic predisposition has been recognized in some cases. Emotional distress. trauma. systemic illness. seasonal changes. and hormonal changes are linked to exacerbations.

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  • 8. 

    Which of the following clients would least likely be at risk of developing skin breakdown?

    • A.

      A client incontinent of urine feces

    • B.

      A client with chronic nutritional deficiencies

    • C.

      A client with decreased sensory perception

    • D.

      A client who is unable to move about and is confined to bed

    Correct Answer
    C. A client with decreased sensory perception
    Explanation
    Bed or chair confinement. inability to move. loss of bowel or bladder control. poor nutrition. absent or inconsistent caregiving. and decreased sensory perception can contribute to the development of skin breakdown. The least likely risk. as presented in the options. is the decreased sensory perception. Options A. B. and D identify physiological conditions. which are the risk priorities.

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  • 9. 

    The nurse prepares to care for a male client with acute cellulites of the lower leg. The nurse anticipates that which of the following will be prescribed for the client?

    • A.

      Cold compress to the affected area

    • B.

      Warm compress to the affected area

    • C.

      Intermittent heat lamp treatments four times daily

    • D.

      Alternating hot and cold compresses continuously

    Correct Answer
    B. Warm compress to the affected area
    Explanation
    Cellulitis is a skin infection into deeper dermal and subcutaneous tissues that results in a deep red erythema without sharp borders and spreads widely throughout tissue spaces. Warm compresses may be used to decrease the discomfort. erythema. and edema. After tissue and blood cultures are obtained. antibiotics will be initiated. The nurse should provide supportive care as prescribed to manage symptoms such as fatigue. fever. chills. headache. and myalgia. Heat lamps can cause more disruption to already inflamed tissue. Cold compresses and alternating cold and hot compresses are not the best measures.

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  • 10. 

    The clinic nurse assesses the skin of a white characteristic is associated with this skin disorder?

    • A.

      Clear. thin nail beds

    • B.

      Red-purplish scaly lesions

    • C.

      Oily skin and no episodes of pruritus

    • D.

      Silvery-white scaly patches on the scalp. elbow. knees. and sacral regions

    Correct Answer
    D. Silvery-white scaly patches on the scalp. elbow. knees. and sacral regions
    Explanation
    Cellulitis is a skin infection into deeper dermal and subcutaneous tissues that results in a deep red erythema without sharp borders and spreads widely throughout tissue spaces. Warm compresses may be used to decrease the discomfort. erythema. and edema. After tissue and blood cultures are obtained. antibiotics will be initiated. The nurse should provide supportive care as prescribed to manage symptoms such as fatigue. fever. chills. headache. and myalgia. Heat lamps can cause more disruption to already inflamed tissue. Cold compresses and alternating cold and hot compresses are not the best measures.

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