NUR 108 NCLEX Questions
Which of the following items are used to perform wound care irrigation? Select all that apply.
A. Clean gloves
B. Sterile gloves
C. Refrigerated irrigating solution
D. 60-mL syringe - ANS A, B, D
Which of the following are primary risk factors for pressure ulcers? Select all that apply.
A. Low-protein diet
B. Insomnia
C. Lengthy surgical procedures
D. Fever
E. Sleeping on a waterbed - ANS A, C, D
An appropriate nursing diagnosis for a client with large areas of skin excoriation resulting from
scratching an allergic rash is:
A. Risk for Impaired Skin Integrity
B. Impaired Skin Integrity
C. Impaired Tissue Integrity
D. Risk for Infection - ANS B
Thirty minutes after application is initiated, the client requests that the nurse leave the heating
pad in place. The nurse explains to the client that:
A. Heat application for longer than thirty minutes can cause the opposite effect (constriction) of
the one desired (dilation)
B. It will be acceptable to leave the pad in place for another thirty minutes - ANS A
Which of the following actions would place a client at the greatest risk for a shearing force injury
to the skin?
A. Walking without shoes
B. Sitting in Fowler's position
C. Lying supine in bed
D. Using a heating pad - ANS B
A client's wound is draining thick yellow material. The nurse correctly describes the drainage as:
A. Sanguineous
B. Serous-sanguineous
C. Serous
D. Purulent - ANS D
A nurse is caring for patients with a variety of wounds. Which would will most likely heal by
primary intention?
A. Cut in the skin from a kitchen knife
B. Excoriated perineal area
C. Abrasion of the skin
D. Pressure ulcer - ANS A
A practitioner orders a wound to be packed with a wet-to-damp gauze dressing. What should
the nurse explain to the client is the primary reason for this type of dressing? - ANS Packing the
wound with wet-to-damp dressings allows epidermal cells to migrate more rapidly across the
bed of the wound surface than dry dressings, thereby facilitating healing. Wet-to-damp
, dressings will also wick exudate up and away from the base of the wound and help to increase
resistance to a wound infection.
You are caring for an assigned client and notice a superficial ulcer on the client's buttock that
appears as a shallow crater involving the epidermis and the dermis. Which of the following
stages would you say best describes this break in skin integrity?
A. Stage I
B. Stage II
C. Stage III
D. Stage IV - ANS B
When caring for an obese client 4 to 5 days post-surgery, who has nausea and occasional
vomiting and is not keeping fluids down well, which of the following would you be most
concerned about?
A. Post-surgical hemorrhage and anemia
B. Wound dehiscence and evisceration
C. Impaired skin integrity and decubitus ulcers
D. Loss of motility and paralytic ileus - ANS B
Which client information collected by the nurse reflects a systemic response to a wound
infection?
A. Hyperthermia
B. Exudate
C. Edema
D. Pain - ANS A
You find that your newly assigned client has very shiny skin on their legs, has little or no leg hair,
and the client reports that their skin damages easily. You would suspect that these signs and
symptoms are related to:
A. Overuse of caustic products to strip the leg hair.
B. Chronic neurological pathology.
C. Impaired peripheral arterial circulation.
D. Inherited reduction in sweat glands and hair follicles. - ANS C
A registered nurse arrives at work and is told to "float" to the ICU for the day because the ICU is
understaffed and needs an additional nurse to care for the clients. The nurse has never worked
in the ICU. Which of the following is the most appropriate nursing action?
A. refuse to float in the ICU
B. call the hospital lawyer
C. call the nursing supervisor
D. report to the ICU and identify tasks that can be safely performed - ANS D
The nurse notices that a colleague's behaviors have changed during the past month. Which
behaviors could indicate signs of impairment? Select all that apply
A. Is increasingly absent from the nursing unit during the shift.
B. Interacts well with others
C. "Forgets" to sign out for administration of controlled substances.
D. Offers to administer prn opiates for other nurse's clients
E. Can say "no" to requests to work more shifts. - ANS A, C, D
Which of the following items are used to perform wound care irrigation? Select all that apply.
A. Clean gloves
B. Sterile gloves
C. Refrigerated irrigating solution
D. 60-mL syringe - ANS A, B, D
Which of the following are primary risk factors for pressure ulcers? Select all that apply.
A. Low-protein diet
B. Insomnia
C. Lengthy surgical procedures
D. Fever
E. Sleeping on a waterbed - ANS A, C, D
An appropriate nursing diagnosis for a client with large areas of skin excoriation resulting from
scratching an allergic rash is:
A. Risk for Impaired Skin Integrity
B. Impaired Skin Integrity
C. Impaired Tissue Integrity
D. Risk for Infection - ANS B
Thirty minutes after application is initiated, the client requests that the nurse leave the heating
pad in place. The nurse explains to the client that:
A. Heat application for longer than thirty minutes can cause the opposite effect (constriction) of
the one desired (dilation)
B. It will be acceptable to leave the pad in place for another thirty minutes - ANS A
Which of the following actions would place a client at the greatest risk for a shearing force injury
to the skin?
A. Walking without shoes
B. Sitting in Fowler's position
C. Lying supine in bed
D. Using a heating pad - ANS B
A client's wound is draining thick yellow material. The nurse correctly describes the drainage as:
A. Sanguineous
B. Serous-sanguineous
C. Serous
D. Purulent - ANS D
A nurse is caring for patients with a variety of wounds. Which would will most likely heal by
primary intention?
A. Cut in the skin from a kitchen knife
B. Excoriated perineal area
C. Abrasion of the skin
D. Pressure ulcer - ANS A
A practitioner orders a wound to be packed with a wet-to-damp gauze dressing. What should
the nurse explain to the client is the primary reason for this type of dressing? - ANS Packing the
wound with wet-to-damp dressings allows epidermal cells to migrate more rapidly across the
bed of the wound surface than dry dressings, thereby facilitating healing. Wet-to-damp
, dressings will also wick exudate up and away from the base of the wound and help to increase
resistance to a wound infection.
You are caring for an assigned client and notice a superficial ulcer on the client's buttock that
appears as a shallow crater involving the epidermis and the dermis. Which of the following
stages would you say best describes this break in skin integrity?
A. Stage I
B. Stage II
C. Stage III
D. Stage IV - ANS B
When caring for an obese client 4 to 5 days post-surgery, who has nausea and occasional
vomiting and is not keeping fluids down well, which of the following would you be most
concerned about?
A. Post-surgical hemorrhage and anemia
B. Wound dehiscence and evisceration
C. Impaired skin integrity and decubitus ulcers
D. Loss of motility and paralytic ileus - ANS B
Which client information collected by the nurse reflects a systemic response to a wound
infection?
A. Hyperthermia
B. Exudate
C. Edema
D. Pain - ANS A
You find that your newly assigned client has very shiny skin on their legs, has little or no leg hair,
and the client reports that their skin damages easily. You would suspect that these signs and
symptoms are related to:
A. Overuse of caustic products to strip the leg hair.
B. Chronic neurological pathology.
C. Impaired peripheral arterial circulation.
D. Inherited reduction in sweat glands and hair follicles. - ANS C
A registered nurse arrives at work and is told to "float" to the ICU for the day because the ICU is
understaffed and needs an additional nurse to care for the clients. The nurse has never worked
in the ICU. Which of the following is the most appropriate nursing action?
A. refuse to float in the ICU
B. call the hospital lawyer
C. call the nursing supervisor
D. report to the ICU and identify tasks that can be safely performed - ANS D
The nurse notices that a colleague's behaviors have changed during the past month. Which
behaviors could indicate signs of impairment? Select all that apply
A. Is increasingly absent from the nursing unit during the shift.
B. Interacts well with others
C. "Forgets" to sign out for administration of controlled substances.
D. Offers to administer prn opiates for other nurse's clients
E. Can say "no" to requests to work more shifts. - ANS A, C, D
