Integumentary
NCLEX® practice.

Free practice set · 2 questions

2 more free integumentary NCLEX-RN® practice questions

Real questions from the same bank the app serves. Pick an answer in your head, then open the rationale to see why the correct option holds and why each other option falls short. No account needed for these.

1. Question 1 of 2 · Skin Integrity, Wounds & Burns

   The nurse is caring for a 68-year-old man on postoperative day 2 after bowel surgery. He is bedbound, has decreased sensation in both feet, and has urinary incontinence with two episodes overnight. His Braden score is 11 (sensory 2, moisture 2, activity 1, mobility 2, nutrition 2, friction/shear 2), indicating high risk. The sacrum has a 3-cm open area covered completely by yellow slough with scant drainage; the surrounding skin is damp with shear marks. Intake is about 40% of meals, and albumin is 2.7 g/dL. What should the nurse do first?

   1. AGently massage the sacrum, then place him on a ring cushion to improve circulation while limiting painful turns.
   2. BDocument the wound as stage 3 and continue the scheduled turn after he finishes sleeping.
   3. CReposition him now, off-load the sacrum and heels, and initiate pressure redistribution, moisture protection, and nutrition support.
   4. DLeave the damp brief in place until the next assessment and focus on applying a more advanced topical dressing.
   Show the answer and rationale

   Correct answer: C. Reposition him now, off-load the sacrum and heels, and initiate pressure redistribution, moisture protection, and nutrition support.

   Repositioning and immediately removing pressure are the priority for this high-risk client, followed by a complete prevention bundle. A Braden score of 11 indicates high risk, so scheduled repositioning at least every 2 hours, a pressure-redistribution surface, heel off-loading, moisture control, skin protection, and nutrition support are indicated. Because slough obscures the wound bed, the injury is unstageable rather than stage 3 or 4; it should not be massaged. A ring cushion concentrates pressure around the wound, delaying repositioning permits ischemia, retained moisture promotes maceration, and topical treatment alone cannot correct poor protein and calorie intake.

   A. Gently massage the sacrum, then place him on a ring cushion to improve circulation while limiting painful turns.

   Massaging a reddened or injured bony prominence can worsen deeper tissue damage rather than improve circulation. A donut or ring cushion is also unsafe because it concentrates pressure around the wound. The correct approach is pressure off-loading with a redistribution surface and scheduled repositioning.

   B. Document the wound as stage 3 and continue the scheduled turn after he finishes sleeping.

   A wound completely covered by slough cannot be assigned stage 3 because the depth and tissue type cannot be visualized; it is unstageable. Delaying the turn to preserve sleep is also unsafe for a high-risk, immobile client because prolonged unrelieved pressure can cause ischemia. Turns may be coordinated with care, not skipped.

   C. Reposition him now, off-load the sacrum and heels, and initiate pressure redistribution, moisture protection, and nutrition support.

   This action immediately removes pressure from an unstageable injury and starts the prevention bundle required for a Braden score of 11. Heel off-loading, moisture protection, and nutrition support address his additional risks and support healing; the wound must be reassessed rather than massaged or assigned a numerical stage while its base is obscured.

   D. Leave the damp brief in place until the next assessment and focus on applying a more advanced topical dressing.

   Leaving urine against the skin promotes moisture-associated damage, maceration, and further shear even if redness is not yet visible. Topical dressing changes alone cannot address high pressure risk or poor intake. The brief should be changed promptly, barrier protection applied, and nutrition and hydration optimized along with pressure relief.

2. Question 2 of 2 · Skin Integrity, Wounds & Burns

   The nurse is caring for a 34-year-old woman in the emergency department on postoperative day 3 after laparoscopic appendectomy. She was diagnosed with an incisional infection; before treatment, temperature was 38.9°C, WBC 15,000/mm³, and creatinine 0.8 mg/dL. The goals are temperature below 38°C and a decreasing WBC within 48–72 hours. She has received IV vancomycin 1 g every 12 hours for 48 hours. Temperature is 39.1°C, WBC 16,800/mm³, and creatinine 1.6 mg/dL; the incision is more tender with scant drainage. Which action should the nurse take next?

   1. ADocument that the client tolerated the antibiotic treatment well and continue the current plan.
   2. BRecord the antibiotic as ineffective because the temperature remained elevated two hours after the first dose.
   3. CContinue vancomycin unchanged for another 72 hours before communicating the lack of improvement.
   4. DHold the next vancomycin dose and promptly notify the health care provider of failed goals and worsening renal function.
   Show the answer and rationale

   Correct answer: D. Hold the next vancomycin dose and promptly notify the health care provider of failed goals and worsening renal function.

   Hold the next vancomycin dose and promptly notify the health care provider because the treatment is not meeting its measurable goals and is producing a concerning adverse response. Temperature is 39.1°C versus the goal below 38°C, and WBC increased to 16,800/mm³ rather than declining within the 48–72-hour evaluation period. Creatinine also rose from 0.8 to 1.6 mg/dL, suggesting reduced renal safety. The nurse should communicate these findings, support an evidence-based therapy change, and establish a reassessment interval. “Tolerated well” lacks a measurable comparison; continuing ineffective therapy delays change; judging therapy after two hours is premature; ignoring renal injury is unsafe; an older unrelated baseline would be inappropriate; and independently changing a dose outside ordered parameters exceeds RN authority.

   A. Document that the client tolerated the antibiotic treatment well and continue the current plan.

   This does not evaluate effectiveness. The measurable findings are temperature 39.1°C versus a goal below 38°C and WBC 16,800/mm³ versus the expected downward trend within 48–72 hours. Saying the client tolerated treatment does not compare an outcome with the plan, and continuing the same therapy also fails to address the rising creatinine.

   B. Record the antibiotic as ineffective because the temperature remained elevated two hours after the first dose.

   Two hours after an initial antibiotic dose is generally too early to declare treatment ineffective; clinical response must be judged at the medication’s expected evaluation interval. However, that timing is not the situation here: this client has received therapy for 48 hours and now has worsening infection indicators and renal function.

   C. Continue vancomycin unchanged for another 72 hours before communicating the lack of improvement.

   This continues an intervention despite failure to meet its time-defined goals. After 48 hours, the temperature remains above 38°C and the WBC has risen, while creatinine increased from 0.8 to 1.6 mg/dL. The nurse should reassess, notify the health care provider, and help modify the plan rather than wait another 72 hours.

   D. Hold the next vancomycin dose and promptly notify the health care provider of failed goals and worsening renal function.

   This action compares current outcomes with specific goals and recognizes that the plan is failing: temperature is 39.1°C instead of below 38°C, and WBC is rising rather than decreasing within 48–72 hours. The creatinine increase from 0.8 to 1.6 mg/dL creates a safety concern, so holding the next dose and promptly collaborating with the health care provider supports timely, safe plan modification.