NCLEX-RN — Integumentary & Sensory flashcards
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Pressure injury stages and Braden, wound drainage and healing, dehiscence and evisceration, burns and grafts, skin infections and cancers, glaucoma, cataract and retinal care, eye drop technique, Ménière's, otitis media, hearing aids, and sensory safety.
Learn deck · part of NCLEX-RN · written against: NCSBN 2026 NCLEX-RN Test Plan, in effect from 1 April 2026 (Next Generation NCLEX; client-needs categories and percentages unchanged from 2023, fact-checked 2026-10-11). Updated 2026-10-10.
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A reddened area over a client's sacrum does not fade when the nurse presses on it, and the skin is intact. Which pressure injury stage is this?Stage 1: intact skin with nonblanchable redness. In darker skin the redness may not show, so the nurse also feels for warmth, firmness, or bogginess compared with nearby skin.Pressure Injuries
Watch out: redness that blanches under the finger is not yet a pressure injury; relieve the pressure and recheck. -
How is a stage 2 pressure injury described?Partial-thickness skin loss with exposed dermis: a shallow, pink or red, moist wound bed, or an intact or ruptured serum-filled blister. No fat, slough, or eschar is visible.Pressure Injuries
Watch out: shallow, diffuse skin loss in the perineum or skin folds from urine or stool is moisture-associated damage, not a stage 2 pressure injury. -
How do superficial, partial-thickness, and full-thickness burns differ in appearance and pain?Superficial (like sunburn): red, painful, no blisters. Partial-thickness: blisters, moist red or mottled base, and usually severe pain. Full-thickness: dry, leathery, white, brown, or black, and often painless because the nerve endings are destroyed.Burns
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How does the rule of nines divide an adult's body surface?Head and neck 9%, each arm 9%, front of the trunk 18%, back of the trunk 18%, each leg 18%, and the perineum 1%, for a total of 100%.Burns
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A client has a warm, red, swollen, tender area on the lower leg with poorly defined edges. What does the nurse suspect, and how is it monitored?Cellulitis, a bacterial infection of the skin and subcutaneous tissue. The nurse marks the border with a pen to track spread, elevates the limb, gives the ordered antibiotics, and reports red streaks, fever, or rapid spread.Skin Conditions
Watch out: a deep vein thrombosis can also make the calf warm, red, and swollen, so report new calf swelling rather than assume cellulitis. -
How does open-angle glaucoma typically progress, and why is screening important?Open-angle glaucoma is gradual and painless: pressure damages the optic nerve and peripheral vision is lost first, leading to tunnel vision. Clients often notice nothing until damage is permanent, so regular eye pressure and optic nerve checks catch it early.Eye Disorders
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How does the nurse instill eye drops correctly?Tilt the head back, pull down the lower lid to form a pocket, have the client look up, and place the drop into the conjunctival sac, not onto the cornea, without touching the tip to the eye. The client closes the eye gently and the nurse presses on the inner corner (nasolacrimal duct) for a minute or two.Eye Medications & Surgery
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Which triad of symptoms defines Ménière's disease?Episodes of vertigo, tinnitus, and fluctuating sensorineural hearing loss, often with a feeling of fullness in the affected ear.Ear Disorders
Why: excess endolymph distends the inner ear's fluid system, disturbing the balance and hearing organs together. -
How does the nurse communicate with a client who is hard of hearing?Get the client's attention first, face the client in good light, reduce background noise, and speak clearly at a normal pace in a lower pitch without shouting. Rephrase rather than repeat, and use writing or a qualified interpreter when needed; age-related loss affects high frequencies most.Sensory Safety
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How do serous, sanguineous, serosanguineous, and purulent wound drainage differ?Wound Care
- Serous: clear and watery
- Sanguineous: bright red blood
- Serosanguineous: thin, pale pink, normal early in healing
- Purulent: thick, yellow, green, or tan, signaling infection.
Watch out: a sudden increase in sanguineous drainage means fresh bleeding and is reported.
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About these cards
Review status: Second-reader reviewed, with corrections applied.
Checked against:
- NCSBN 2026 NCLEX-RN Test Plan, in effect from 1 April 2026 (topic outline only; no text copied)
- OpenStax Maternal-Newborn Nursing, OpenStax Psychiatric-Mental Health Nursing and OpenStax Medical-Surgical Nursing, consulted as references where available; no text copied.
- Pressure injury staging and the moisture-damage distinction checked against the NPIAP pressure injury stages (2016); scabies care against CDC parasite guidance (public domain); wound care against Open RN Nursing Skills (Chippewa Valley Technical College, CC BY 4.0); reference only, no text copied.
- Prevention measures checked against the NPIAP/EPUAP/PPPIA International Guideline, 4th edition (2026); eye-drug effects against FDA prescribing information on DailyMed; shingles teaching against CDC guidance; eye care against MedlinePlus and the reference below; burn resuscitation against the American Burn Association burn shock resuscitation guideline (2023); reference only, no text copied.
- OpenStax Clinical Nursing Skills, consulted as a reference; no text copied.
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