1. Nurse Jay 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
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
3. Nurse Kate 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.
4. Nurse May 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.
5. Nurse Jane 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
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?
d. Back of the hands
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
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
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
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
11. The clinic nurse notes that the physician has documented a diagnosis of herpes zoster (shingles) in the male client’s chart. Based on an understanding of the cause of this disorder, the nurse determines that this definitive diagnosis was made following which diagnostic test?
a. Patch test
b. Skin biopsy
c. Culture of the lesion
d. Woo’s light examination
12. The nurse is assigned to care for a female client with herpes zoster (Shingles). Which of the following characteristics would the nurse expect to note when assessing the lesions of this infection?
a. Clustered skin vesicles
b. A generalized body rash
c. Small blue-white spots with a red base
d. A fiery red, edematous rash on the cheeks
13. When assessing a lesion diagnosed as malignant melanoma, the nurse in-charge most likely expects to note which of the following?
a. An irregular shaped lesion
b. A small papule with a dry, rough scale
c. A firm, nodular lesion topped with crust
d. A pearly papule with a central crater and a waxy border
14. The nurse prepares discharge instructions for a male client following cryosurgery for the treatment of a malignant skin lesion. Which of the following should the nurse include in the instruction?
a. Avoid showering for 7 to 10 days
b. Apply ice to the site to prevent discomfort
c. Apply alcohol-soaked dressing twice a day
d. Clean the site with hydrogen peroxide to prevent infection
15. Nurse Carl reviews the client’s chart and notes that the physician has documented a diagnosis of paronychia. Based on this diagnosis, which of the following would the nurse expect to note during the assessment?
a. Red shiny skin around the nail bed
b. White taut skin in the popliteal area
c. White silvery patches on the elbows
d. Swelling of the skin near the parotid gland
16. A male client arrives at the emergency room and has experienced frostbites to the right hand. Which of the following would the nurse note on assessment of the client’s hand?
a. A pink, edematous hand
b. A fiery red skin with edema in the nail beds
c. Black fingertips surrounded by an erythematous rash
d. A white color to the skin, which is insensitive to touch
17. The evening nurse reviews the nursing documentation in the male client’s chart and notes that the day nurse has documented that the client has a stage II pressure ulcer in the sacral area. Which of the following would the nurse expect to note on assessment of the client’s sacral area?
a. Intact skin
b. Full-thickness skin loss
c. Exposed bone, tendon, or muscle
d. Partial-thickness skin loss of the dermis
18. Nurse Ivy is implementing a teaching plan to a group of adolescents regarding the causes of acne. Which of the following is an appropriate nursing statement regarding the cause of this disorder?
a. “Acne is caused by oily skin”
b. “The actual cause is not known”
c. “Acne is caused by eating chocolate”
d. “Acne is caused as a result of exposure to heat and humidity”
19. The nurse is reviewing the health care record of a male clients scheduled to be seen at the health care clinic. The nurse determines that which of the following individuals is at the greatest risk for development of an integumentary disorder?
a. An adolescent
b. An older female
c. A physical education teacher
d. An outdoor construction worker
20. A male client schedule for a skin biopsy is concerned and asks the nurse how painful the procedure is. The appropriate response by the nurse is:
a. “There is no pain associated with this procedure”
b. “The local anesthetic may cause a burning or stinging sensation”
c. A preoperative medication will be given so you will be sleeping and will not feel any pain”
d. “There is some pain, but the physician will prescribe an opioid analgesic following the procedure”
21. The nurse is teaching a female client with a leg ulcer about tissue repair and wound healing. Which of the following statements by the client indicates effective teaching?
a. “I’ll limit my intake of protein.”
b. “I’ll make sure that the bandage is wrapped tightly.”
c. “My foot should feel cold.”
d. “I’ll eat plenty of fruits and vegetables.”
22. Following a full-thickness (third-degree) burn of his left arm, a male client is treated with artificial skin. The client understands postoperative care of artificial skin when he states that during the first 7 days after the procedure, he will restrict:
a. range of motion.
b. protein intake.
c. going outdoors.
d. fluid ingestion.
23. Following a small-bowel resection, a male client develops fever and anemia. The surface surrounding the surgical wound is warm to the touch and necrotizing fasciitis is suspected. Another manifestation that would most suggest necrotizing fasciitis is:
c. pressurelike pain.
24. While in a skilled nursing facility, a female client contracted scabies, which is diagnosed the day after discharge. The client is living at her daughter’s home, where six other persons are living. During her visit to the clinic, she asks a staff nurse, “What should my family do?” The most accurate response from the nurse is:
a. “All family members will need to be treated.”
b. “If someone develops symptoms, tell him to see a physician right away.”
c. “Just be careful not to share linens and towels with family members.”
d. “After you’re treated, family members won’t be at risk for contracting scabies.”
25. The nurse is assessing a male client admitted with second- and third-degree burns on the face, arms, and chest. Which finding indicates a potential problem?
a. Partial pressure of arterial oxygen (PaO2) value of 80 mm Hg
b. Urine output of 20 ml/hour
c. White pulmonary secretions
d. Rectal temperature of 100.6° F (38° C)
26. A female client exhibits s purplish bruise to the skin after a fall. The nurse would document this finding most accurately using which of the following terms?
27. An older client’s physical examination reveals the presence of a number of bright red-colored lesions scattered on the trunk and tights. The nurse interprets that this indicates which of the following lesions due to alterations in blood vessels of the skin?
a. Cherry angioma
b. Spider angioma
c. Venous star
28. A nurse is reviewing the medical record of a male client to be admitted to the nursing unit and notes documentation of reticular skin lesions. The nurse expects that these lesions will appear to be:
c. Shaped like an arc
d. Net-like appearance
29. A male client seen in an ambulatory clinic has a butterfly rash across the nose. The nurse interprets that this finding is consistent with early manifestations of which of the following disorders?
b. Perncious anemia
c. Cardiopulmonary disorders
d. Systemic lupus erythematosus (SLE)
30. A female client with cellulites of the lower leg has had cultures done on the affected area. The nurse reading the culture report understands that which of the following organisms is not part of the normal flora of the skin?
a. Staphylococcus epidermidis
b. Staphylococcus aureus
c. Escherichia coli (E. coli)
d. Candida albicans
More NCLEX Review