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NRSNG NCLEX PRACTICE QUESTIONS EXAM AND CORRECT ANSWERS
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NRSNG NCLEX PRACTICE QUESTIONSEXAM AND CORRECT ANSWERS
A nurse assesses an 86-year-old patient who is a client at a long-term care facility. The
nurse uses the Braden scale to determine the patients level of risk for skin breakdown.
After completing the assessment the nurse gives the patient a score of 8. Which of the
following best describes this patients risk of skin breakdown?
A. High Risk
B. Mild Risk
C. Moderate
D. Very Low Risk - Answer Correct Answer:
A. High Risk
Rationale:
The Braden Scale is an assessment tool used to determine the level of risk a patient has
for skin breakdown. The Braden Scale uses several measures that can contribute to
skin breakdown; the nurse then gives the patient a score based on these measures and
adds the total. A low score of 8 indicates that the patient is at high risk of skin
breakdown.
A patient arrives in the recovery room after surgical wound debridement with a
negative-pressure wound system in place. Which best describes how this type of
therapy helps a wound to heal?
A. The wound vacuum removes granulation tissue if it develops
B. The negative pressure decreases collagen production in the wound bed
C. The wound vacuum stimulates keratinocyte formation
D. The negative pressure draws the edges of the wound together - Answer Correct
Answer:
D. The negative pressure draws the edges of the wound together
Rationale:
A negative-pressure wound system may be used for some types of wounds as part of
healing. The system utilizes slight negative pressure like a vacuum to draw the edges of
the wound together, remove bacteria that could cause infection, and stimulate
circulation to the site to promote healing.
An immobile client has developed an area of skin breakdown on his hip. The nurse
, recognizes that there are several factors that potentially contributed to this skin
breakdown. Select all of the following extrinsic factors that would have contributed to
skin breakdown in a patient.
A. Nutrition
B. Moisture
C. Friction
D. Shear
E. Tissue Perfusion - Answer Correct Answer:
B. Moisture
C. Friction
D. Shear
Rationale:
Skin breakdown can occur to various factors; extrinsic factors are those in the
environment that most likely contribute to a patient's loss of skin integrity. Examples of
extrinsic factors that contribute to skin breakdown include moisture on the patient's
skin and skin injury, such as through friction or shear forces.
An elderly patient has developed a pressure ulcer from long periods of immobility. The
nurse places a transparent dressing over the top of the wound. Which best describes
why a nurse would use a transparent dressing?
A. It is stable even if it becomes wet
B. It has the ability to absorb more exudate
C. It allows the nurse to visualize the wound
D. It is usually impregnated with antimicrobial solution - Answer Correct Answer:
C. It allows the nurse to visualize the wound
Rationale:
There are a number of dressing types a nurse may use when caring for a patients
wound; the type to choose depends on the extent and depth of the wound, as well as the
amount of exudate present. The nurse may apply a transparent dressing over the wound
to protect it and to still visualize the wound underneath. A transparent dressing is
typically not useful when there are large amounts of exudate present.
The nurse is charting a skin assessment on the newly admitted client. The client has a
puss filled hair follicle on their neck. The nurse should chart this using what
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