NCLEX RN Integumentary Disorders
Practice Exam 100 Questions And
Correct Answers (Verified Answers)
Plus Rationales 2026
1. A nurse assesses a client with a pressure injury over the sacrum. The
wound has full-thickness skin loss with visible adipose tissue but no exposed
muscle, tendon, or bone. How should the nurse classify the injury?
A. Stage 1
B. Stage 2
C. Stage 3
D. Stage 4
Answer: Stage 3
Rationale: Stage 3 pressure injury involves full-thickness skin loss with visible
adipose tissue. Muscle, tendon, cartilage, and bone are not exposed.
2. Which intervention is most appropriate for preventing pressure injuries in
an immobile client?
A. Massage reddened bony prominences
B. Reposition the client at regular intervals
C. Restrict oral fluids
D. Keep the head of the bed elevated at 60 degrees
Answer: Reposition the client at regular intervals
Rationale: Regular repositioning relieves prolonged pressure and helps
maintain tissue perfusion. Massage should not be performed over reddened
areas because it can cause additional tissue injury.
,3. A client with a stage 1 pressure injury has intact skin with persistent
nonblanchable erythema. Which intervention should the nurse prioritize?
A. Apply vigorous massage
B. Relieve pressure from the affected area
C. Debride the area
D. Apply a wet-to-dry dressing
Answer: Relieve pressure from the affected area
Rationale: Stage 1 pressure injuries require immediate pressure relief to
prevent progression to deeper tissue damage.
4. A client with a burn injury has a dry, leathery, painless area of skin that
appears white and charred. Which type of burn is most likely?
A. Superficial
B. Superficial partial-thickness
C. Deep partial-thickness
D. Full-thickness
Answer: Full-thickness
Rationale: Full-thickness burns destroy the epidermis and dermis and may
damage deeper tissues. The wound may appear white, brown, black, or
charred and may be painless because nerve endings are destroyed.
5. A client has a superficial partial-thickness burn. Which finding should the
nurse expect?
A. Dry, leathery skin
B. Blisters and severe pain
C. Charred tissue without sensation
D. Exposed bone
Answer: Blisters and severe pain
,Rationale: Superficial partial-thickness burns damage the epidermis and part
of the dermis, producing erythema, blisters, moisture, and significant pain.
6. Which finding in a client with a major burn requires immediate nursing
attention?
A. Mild anxiety
B. Hoarse voice and singed nasal hair
C. Pain rated 6/10
D. Blister formation
Answer: Hoarse voice and singed nasal hair
Rationale: Hoarseness and singed nasal hair may indicate inhalation injury
and impending airway edema. Airway assessment and intervention are
priorities.
7. The nurse is caring for a client immediately after a major thermal burn.
Which intervention has the highest priority?
A. Apply topical antibiotics
B. Establish and maintain the airway
C. Begin range-of-motion exercises
D. Apply moisturizing lotion
Answer: Establish and maintain the airway
Rationale: Airway and breathing are the highest priorities in major burns,
especially when inhalation injury is suspected.
8. A client with extensive burns is receiving fluid resuscitation. Which
assessment best indicates adequate renal perfusion?
A. Blood pressure of 90/50 mm Hg
B. Urine output of 0.5 mL/kg/hr or greater
C. Heart rate of 130/min
D. Dark amber urine
, Answer: Urine output of 0.5 mL/kg/hr or greater
Rationale: Urine output is an important indicator of renal perfusion and
adequacy of fluid resuscitation in adult burn clients.
9. Which electrolyte abnormality is most likely during the early phase after a
major burn?
A. Hyperkalemia
B. Hypokalemia
C. Hypercalcemia
D. Hypermagnesemia
Answer: Hyperkalemia
Rationale: Cellular destruction releases intracellular potassium into the
bloodstream, making hyperkalemia common during the early phase after
severe burns.
10. A client with a burn injury asks why nutritional needs have increased.
What is the nurse's best response?
A. "Burn injuries decrease metabolism."
B. "Your body requires additional calories and protein for healing."
C. "Protein intake must be restricted."
D. "You need fewer calories during wound healing."
Answer: "Your body requires additional calories and protein for healing."
Rationale: Major burns produce a hypermetabolic and hypercatabolic state,
increasing energy and protein requirements for tissue repair and immune
function.
11. A client with psoriasis asks what commonly triggers exacerbations. Which
response is appropriate?
Practice Exam 100 Questions And
Correct Answers (Verified Answers)
Plus Rationales 2026
1. A nurse assesses a client with a pressure injury over the sacrum. The
wound has full-thickness skin loss with visible adipose tissue but no exposed
muscle, tendon, or bone. How should the nurse classify the injury?
A. Stage 1
B. Stage 2
C. Stage 3
D. Stage 4
Answer: Stage 3
Rationale: Stage 3 pressure injury involves full-thickness skin loss with visible
adipose tissue. Muscle, tendon, cartilage, and bone are not exposed.
2. Which intervention is most appropriate for preventing pressure injuries in
an immobile client?
A. Massage reddened bony prominences
B. Reposition the client at regular intervals
C. Restrict oral fluids
D. Keep the head of the bed elevated at 60 degrees
Answer: Reposition the client at regular intervals
Rationale: Regular repositioning relieves prolonged pressure and helps
maintain tissue perfusion. Massage should not be performed over reddened
areas because it can cause additional tissue injury.
,3. A client with a stage 1 pressure injury has intact skin with persistent
nonblanchable erythema. Which intervention should the nurse prioritize?
A. Apply vigorous massage
B. Relieve pressure from the affected area
C. Debride the area
D. Apply a wet-to-dry dressing
Answer: Relieve pressure from the affected area
Rationale: Stage 1 pressure injuries require immediate pressure relief to
prevent progression to deeper tissue damage.
4. A client with a burn injury has a dry, leathery, painless area of skin that
appears white and charred. Which type of burn is most likely?
A. Superficial
B. Superficial partial-thickness
C. Deep partial-thickness
D. Full-thickness
Answer: Full-thickness
Rationale: Full-thickness burns destroy the epidermis and dermis and may
damage deeper tissues. The wound may appear white, brown, black, or
charred and may be painless because nerve endings are destroyed.
5. A client has a superficial partial-thickness burn. Which finding should the
nurse expect?
A. Dry, leathery skin
B. Blisters and severe pain
C. Charred tissue without sensation
D. Exposed bone
Answer: Blisters and severe pain
,Rationale: Superficial partial-thickness burns damage the epidermis and part
of the dermis, producing erythema, blisters, moisture, and significant pain.
6. Which finding in a client with a major burn requires immediate nursing
attention?
A. Mild anxiety
B. Hoarse voice and singed nasal hair
C. Pain rated 6/10
D. Blister formation
Answer: Hoarse voice and singed nasal hair
Rationale: Hoarseness and singed nasal hair may indicate inhalation injury
and impending airway edema. Airway assessment and intervention are
priorities.
7. The nurse is caring for a client immediately after a major thermal burn.
Which intervention has the highest priority?
A. Apply topical antibiotics
B. Establish and maintain the airway
C. Begin range-of-motion exercises
D. Apply moisturizing lotion
Answer: Establish and maintain the airway
Rationale: Airway and breathing are the highest priorities in major burns,
especially when inhalation injury is suspected.
8. A client with extensive burns is receiving fluid resuscitation. Which
assessment best indicates adequate renal perfusion?
A. Blood pressure of 90/50 mm Hg
B. Urine output of 0.5 mL/kg/hr or greater
C. Heart rate of 130/min
D. Dark amber urine
, Answer: Urine output of 0.5 mL/kg/hr or greater
Rationale: Urine output is an important indicator of renal perfusion and
adequacy of fluid resuscitation in adult burn clients.
9. Which electrolyte abnormality is most likely during the early phase after a
major burn?
A. Hyperkalemia
B. Hypokalemia
C. Hypercalcemia
D. Hypermagnesemia
Answer: Hyperkalemia
Rationale: Cellular destruction releases intracellular potassium into the
bloodstream, making hyperkalemia common during the early phase after
severe burns.
10. A client with a burn injury asks why nutritional needs have increased.
What is the nurse's best response?
A. "Burn injuries decrease metabolism."
B. "Your body requires additional calories and protein for healing."
C. "Protein intake must be restricted."
D. "You need fewer calories during wound healing."
Answer: "Your body requires additional calories and protein for healing."
Rationale: Major burns produce a hypermetabolic and hypercatabolic state,
increasing energy and protein requirements for tissue repair and immune
function.
11. A client with psoriasis asks what commonly triggers exacerbations. Which
response is appropriate?
