ATI RN
NCLEX Practice Questions Skin Integrity and Wound Care Questions
Question 1 of 5
A patient is being discharged 4 days after hip arthroplasty using the posterior approach. Which patient action requires intervention by the nurse?
Correct Answer: B
Rationale: The correct answer is B because leaning over to pull on shoes and socks can put excessive strain on the hip joint, potentially leading to dislocation or injury post-hip arthroplasty. This action should be avoided to prevent complications. The other choices (A, C, D) are safe post-hip arthroplasty actions that promote proper weight-bearing, mobility, and independence without risking injury or dislocation.
Question 2 of 5
After change-of-shift report, which patient should the nurse assess first?
Correct Answer: D
Rationale: The correct answer is D. The nurse should assess the patient with a repaired right femoral shaft fracture complaining of tightness in the calf first. This could indicate a potential complication like deep vein thrombosis (DVT), which is a serious condition requiring immediate attention to prevent further harm. Assessing for DVT is crucial as it can lead to pulmonary embolism if left untreated. Choice A is incorrect as facial pain in a patient with a repaired mandibular fracture, while important, does not pose an immediate life-threatening risk. Choice B is incorrect as an externally rotated leg in a patient with an unrepaired intracapsular left hip fracture may indicate a hip dislocation, but it is not as urgent as assessing for a potential DVT. Choice C is incorrect as wrist swelling and deformity in a patient with an unrepaired Colles’ fracture, while concerning, does not require immediate attention compared to the potential complication of DVT in the patient with the femoral shaft
Question 3 of 5
A patient whose employment requires frequent lifting has a history of chronic back pain. After the nurse has taught the patient about correct body mechanics, which patient statement indicates the teaching has been effective?
Correct Answer: B
Rationale: The correct answer is B because the patient recognizing the importance of strengthening and supporting their back aligns with the goal of preventing further back pain. Strengthening exercises can help improve muscle support and reduce the risk of injury during lifting tasks. Choice A is incorrect as lifting above the waist with a straight back may still put strain on the back. Choice C is incorrect as avoiding lifting altogether is not a practical solution for someone whose job involves frequent lifting. Choice D is incorrect as sleeping with hips and knees extended may not necessarily prevent back strain during lifting activities.
Question 4 of 5
After laminectomy with a spinal fusion to treat a herniated disc, a patient reports numbness and tingling of the right lower leg. The first action the nurse should take is to
Correct Answer: A
Rationale: The correct answer is A: report the patient’s complaint to the surgeon. The numbness and tingling in the right lower leg could indicate nerve damage post-laminectomy with spinal fusion. It is crucial to inform the surgeon immediately to evaluate and address the issue promptly. Checking the preoperative assessment data (B) may not provide immediate insight into the current issue. Checking vital signs for hemorrhage (C) is important but not the priority in this scenario. Turning the patient to the left (D) would not address the underlying cause and could potentially worsen the symptoms. Reporting to the surgeon ensures timely intervention and prevents further complications.
Question 5 of 5
Which actions will the nurse include in the plan of care for a patient with metastatic bone cancer of the left femur(select the one that does not apply)?
Correct Answer: C
Rationale: The correct answer is C because discontinuing the use of sustained-release opioids is not appropriate for a patient with metastatic bone cancer of the left femur. This patient likely experiences severe pain that requires opioids for adequate pain management. Monitoring serum calcium levels (A) is essential due to the risk of hypercalcemia. Teaching about the need for strict bed rest (B) helps prevent fractures and reduces pain. Supporting the left leg when repositioning the patient (D) helps maintain alignment and prevent further damage.