SAUNDERS COMPREHENSIVE
REVIEW FOR NCLEX THREE
Distribution of this document is illegal
,SAUNDERS COMPREHENSIVE REVIEW FOR NCLEX
THREE
1) The nurse performs an assessment on a client admitted
with contact dermatitis. Which signs and symptoms should
the nurse look for?
✓ Lesions with well-defined geometric
margins
2) The nurse is providing home care instructions to the
client who just had surgery for squamous cell carcinoma.
The nurse provides follow-up teaching and explains to the
client to watch for which characteristics of this type of
skin carcinoma?
✓ Firm, nodular lesion topped with a crust
or with a central area of ulceration
3) The nurse is teaching the client about risk factors for
skin cancer. Which statements by the client indicate that
teaching was successful? Select all that apply.
✓ "I have to avoid excessive exposure to
sunlight."
✓ "I am at higher risk for skin cancer
because my mother had one."
4) The nurse is assessing a dark-skinned client for signs of
anemia. The nurse should focus the assessment on which
structures? Select all that apply.
✓ Lips
✓ Conjunctiva
✓ Mucous membranes
5) The nurse is providing teaching to a client who will
undergo chemotherapy for cancer, and alopecia is expected
from the chemotherapeutic agent. Which statement made by
the client indicates a need for further teaching?
✓ "I can't believe my hair loss will be
permanent."
6) The nurse is caring for a client with full-thickness
circumferential burns of the entire trunk of the body.
Which finding suggests that an escharotomy may be
necessary?
Distribution of this document is illegal
, ✓ High pressure alarm keeps sounding on
the ventilator
7) A client with chloasma is extremely stressed about the
change in her facial appearance. Which integumentary
change observed by the nurse is consistent with this
problem?
✓ Blotchy brown macules across the cheeks
and forehead
8) The nurse is planning care for a client who suffered a
burn injury and has a negative self-image related to
keloid formation at the burn site. The keloid formation
is indicative of which condition?
✓ Hypertrophy of collagen fibers
9) The nurse observes the client's sacrum and notes the
following. How will the nurse document this in the
client's medical record? Refer to figure.
View Figure
✓ Stage IV pressure ulcer
10) A client recently diagnosed with chronic kidney disease
requiring hemodialysis has an arteriovenous fistula for
access. The client asks the nurse what complications can
occur with the access site. What complications should the
nurse inform the client about? Select all that apply.
✓ Hepatitis
✓ Infection
11) The nurse has completed discharge teaching for a client
who was admitted for reticular skin lesions. Which
statement by the client indicates understanding of the
discharge instructions?
✓ "I need to assess my skin for lesions
that appear net-like."
12) A client exhibits erythema of the skin. The nurse plans
care, knowing that which factors are responsible for this
finding? Select all that apply.
✓ Fever
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, ✓ Vasodilation
✓ Inflammation
✓ Excessively high environmental
temperature
13) An older client's physical examination reveals the
presence of a fiery star-shaped marking with a circular,
solid center. The nurse recognizes that these findings,
which are caused by capillary radiations extending from
the central arterial body, are representative of which
lesions?
✓ Spider angioma
14) An older client is lying in a supine position. The
nurse understands that the client is at least risk for
skin breakdown in which body area?
✓ Greater trochanter
15) In planning care for the client with psoriasis, the
nurse understands that which represents a priority client
problem?
✓ Altered body image
16) The nurse is performing an admission assessment on a
client diagnosed with paronychia. The nurse should plan
to assess which part of the integumentary system first?
✓ Nails
17) A client exhibits a purplish bruise to the skin after a
fall. The nurse would document this finding in the health
record most accurately using which term?
✓ Ecchymosis
18) A client is diagnosed with a full-thickness burn. What
should the nurse anticipate will be used for final
coverage of the client's burn wound?
✓ Autograft
19) The nurse is providing instructions to a client with
psoriasis who will be receiving ultraviolet (UV) light
therapy. Which statement would be most appropriate for
the nurse to include in the client's instructions?
Distribution of this document is illegal
REVIEW FOR NCLEX THREE
Distribution of this document is illegal
,SAUNDERS COMPREHENSIVE REVIEW FOR NCLEX
THREE
1) The nurse performs an assessment on a client admitted
with contact dermatitis. Which signs and symptoms should
the nurse look for?
✓ Lesions with well-defined geometric
margins
2) The nurse is providing home care instructions to the
client who just had surgery for squamous cell carcinoma.
The nurse provides follow-up teaching and explains to the
client to watch for which characteristics of this type of
skin carcinoma?
✓ Firm, nodular lesion topped with a crust
or with a central area of ulceration
3) The nurse is teaching the client about risk factors for
skin cancer. Which statements by the client indicate that
teaching was successful? Select all that apply.
✓ "I have to avoid excessive exposure to
sunlight."
✓ "I am at higher risk for skin cancer
because my mother had one."
4) The nurse is assessing a dark-skinned client for signs of
anemia. The nurse should focus the assessment on which
structures? Select all that apply.
✓ Lips
✓ Conjunctiva
✓ Mucous membranes
5) The nurse is providing teaching to a client who will
undergo chemotherapy for cancer, and alopecia is expected
from the chemotherapeutic agent. Which statement made by
the client indicates a need for further teaching?
✓ "I can't believe my hair loss will be
permanent."
6) The nurse is caring for a client with full-thickness
circumferential burns of the entire trunk of the body.
Which finding suggests that an escharotomy may be
necessary?
Distribution of this document is illegal
, ✓ High pressure alarm keeps sounding on
the ventilator
7) A client with chloasma is extremely stressed about the
change in her facial appearance. Which integumentary
change observed by the nurse is consistent with this
problem?
✓ Blotchy brown macules across the cheeks
and forehead
8) The nurse is planning care for a client who suffered a
burn injury and has a negative self-image related to
keloid formation at the burn site. The keloid formation
is indicative of which condition?
✓ Hypertrophy of collagen fibers
9) The nurse observes the client's sacrum and notes the
following. How will the nurse document this in the
client's medical record? Refer to figure.
View Figure
✓ Stage IV pressure ulcer
10) A client recently diagnosed with chronic kidney disease
requiring hemodialysis has an arteriovenous fistula for
access. The client asks the nurse what complications can
occur with the access site. What complications should the
nurse inform the client about? Select all that apply.
✓ Hepatitis
✓ Infection
11) The nurse has completed discharge teaching for a client
who was admitted for reticular skin lesions. Which
statement by the client indicates understanding of the
discharge instructions?
✓ "I need to assess my skin for lesions
that appear net-like."
12) A client exhibits erythema of the skin. The nurse plans
care, knowing that which factors are responsible for this
finding? Select all that apply.
✓ Fever
Distribution of this document is illegal
, ✓ Vasodilation
✓ Inflammation
✓ Excessively high environmental
temperature
13) An older client's physical examination reveals the
presence of a fiery star-shaped marking with a circular,
solid center. The nurse recognizes that these findings,
which are caused by capillary radiations extending from
the central arterial body, are representative of which
lesions?
✓ Spider angioma
14) An older client is lying in a supine position. The
nurse understands that the client is at least risk for
skin breakdown in which body area?
✓ Greater trochanter
15) In planning care for the client with psoriasis, the
nurse understands that which represents a priority client
problem?
✓ Altered body image
16) The nurse is performing an admission assessment on a
client diagnosed with paronychia. The nurse should plan
to assess which part of the integumentary system first?
✓ Nails
17) A client exhibits a purplish bruise to the skin after a
fall. The nurse would document this finding in the health
record most accurately using which term?
✓ Ecchymosis
18) A client is diagnosed with a full-thickness burn. What
should the nurse anticipate will be used for final
coverage of the client's burn wound?
✓ Autograft
19) The nurse is providing instructions to a client with
psoriasis who will be receiving ultraviolet (UV) light
therapy. Which statement would be most appropriate for
the nurse to include in the client's instructions?
Distribution of this document is illegal
