SAUNDERS NCLEX REVIEW
QUESTIONS & VERIFIED CORRECT
SOLUTIONS
A client is being admitted to the hospital for treatment of acute cellulitis of the lower left leg.
During the admission assessment, the nurse expects to note which finding?
1. An inflammation of the epidermis only
2. A skin infection of the dermis and underlying hypodermis
3. An acute superficial infection of the dermis and lymphatics
4. An epidermal and lymphatic infection caused by Staphylococcus - correct answer ✔✔2
Rationale: Cellulitis is an infection of the dermis and underlying hypodermis that results in a
deep red erythema without sharp borders and spreads widely throughout tissue spaces. The
skin is erythematous, edematous, tender, and sometimes nodular. Erysipelas is an acute,
superficial, rapidly spreading inflammation of the dermis and lymphatics. The infection is not
superficial and extends deeper than the epidermis. Test-Taking Strategy: Eliminate options 3 and
4 because they are comparable or alike and address the lymphatics. Eliminate option 1 because
of the closed-ended word only.
The nurse is conducting a session about the principles of first aid and is discussing the
interventions for a snakebite to an extremity. The nurse should inform those attending the
session that the first priority intervention in the event of this occurrence is which action?
1. Immobilize the affected extremity.
2. Remove jewelry and constricting clothing from the victim.
, 3. Place the extremity in a position so that it is below the level of the heart.
4. Move the victim to a safe area away from the snake and encourage the victim to rest. -
correct answer ✔✔4
Rationale: In the event of a snakebite, the first priority is to move the victim to a safe area away
from the snake and encourage the victim to rest to decrease venom circulation. Next, jewelry
and constricting clothing are removed before swelling occurs. Immobilizing the extremity and
maintaining the extremity at the heart level would be done next; these actions limit the spread
of the venom. The victim is kept warm and calm. Stimulants such as alcohol or caffeinated
beverages are not given to the victim because these products may speed the absorption of the
venom. The victim should be transported to an emergency facility as soon as possible.
A client calls the emergency department and tells the nurse that he came directly into contact
with poison ivy shrubs. The client tells the nurse that he cannot see anything on the skin and
asks the nurse what to do. The nurse should make which response?
1. "Come to the emergency department."
2. "Apply calamine lotion immediately to the exposed skin areas."
3. "Take a shower immediately, lathering and rinsing several times."
4. "It is not necessary to do anything if you cannot see anything on your skin." - correct answer
✔✔3
Rationale: When an individual comes in contact with a poison ivy plant, the sap from the plant
forms an invisible film on the human skin. The client should be instructed to cleanse the area by
showering immediately and to lather the skin several times and rinse each time in running
water. Removing the poison ivy sap will decrease the likelihood of irritation. Calamine lotion
may be one product recommended for use if dermatitis develops. The client does not need to
be seen in the emergency department at this time.
The clinic nurse assesses the skin of a client with psoriasis after the client has used a new topical
treatment for 2 months. The nurse identifies which characteristics as improvement in the
manifestations of psoriasis? Select all that apply.