ATI RN
NCLEX Questions Skin Integrity and Wound Care Questions
Question 1 of 5
A patient undergoes left above-the-knee amputation with an immediate prosthetic fitting. When the patient arrives on the orthopedic unit after surgery, the nurse should
Correct Answer: A
Rationale: The correct answer is A: assess the surgical site for hemorrhage. After an above-the-knee amputation, assessing the surgical site for hemorrhage is crucial as it helps in early detection and management of any bleeding, which can be life-threatening. Other choices are incorrect: B is wrong as removing the prosthesis can disrupt wound healing; C is incorrect as it doesn't address the immediate post-op concern of hemorrhage; D is incorrect as keeping the residual limb elevated on a pillow may not be the priority over assessing for hemorrhage.
Question 2 of 5
The nurse will determine more teaching is needed if a patient with discomfort from a bunion says, “I will
Correct Answer: D
Rationale: The correct answer is D because wearing only sandals and avoiding closed-toe shoes will not effectively address the discomfort from the bunion. This response indicates a lack of understanding about proper footwear choices to reduce pressure on the bunion. Other choices (A, B, C) show actions that may actually help alleviate discomfort temporarily, like giving away high-heeled shoes, using a bunion pad, or taking ibuprofen. However, these choices do not address the root cause of the issue, which is pressure and friction on the bunion. Therefore, choice D is the correct answer as it highlights the need for further education on appropriate footwear to manage bunion discomfort effectively.
Question 3 of 5
Which nursing action included in the care of a patient after laminectomy can the nurse delegate to experienced unlicensed assistive personnel (UAP)?
Correct Answer: C
Rationale: The correct answer is C because log rolling the patient from side to side every 2 hours is a task that can be safely delegated to experienced unlicensed assistive personnel (UAP). This task helps prevent complications such as pressure ulcers and promotes mobility without risking injury. A: Checking the ability to plantar and dorsiflex the foot requires clinical judgment and may indicate nerve damage, which should be assessed by a licensed nurse. B: Determining the patient's readiness to ambulate involves assessing strength, balance, and coordination, which requires nursing judgment and assessment skills. D: Asking about pain management with PCA involves assessing the effectiveness of the pain control method and potential side effects, which should be done by a licensed nurse.
Question 4 of 5
A client is exhibiting manifestations of superficial dermatophytosis of the skin with skin scaling and nail disintegration. Based on these findings, the nurse can anticipate that the client will be prescribed: Select all that apply.
Correct Answer: A
Rationale: Correct Answer: A - An antifungal like ketoconazole Rationale: Superficial dermatophytosis is a fungal infection of the skin and nails. Antifungals like ketoconazole are specifically designed to treat fungal infections, including dermatophytosis. They work by targeting and killing the fungus responsible for the infection. Therefore, prescribing an antifungal like ketoconazole would be appropriate in this case. Summary of Incorrect Choices: B: An antibiotic like tetracycline - Antibiotics are used to treat bacterial infections, not fungal infections like dermatophytosis. C: Topical corticosteroid - Corticosteroids are used to reduce inflammation and are not effective against fungal infections. D: An antihistamine like Benadryl - Antihistamines are used to treat allergic reactions and itching, not fungal infections.
Question 5 of 5
Dry, itchy plaques on her elbows and knees have prompted a 23-year-old woman to seek care. The clinician has subsequently diagnosed the client with psoriasis, a disorder that results from:
Correct Answer: A
Rationale: The correct answer is A: Increased epidermal cell turnover. Psoriasis is a chronic skin disorder characterized by rapid growth and shedding of skin cells. This results from an increased rate of epidermal cell proliferation, leading to the formation of dry, itchy plaques. Choice B, IgE-mediated immune reaction, is incorrect as psoriasis is not primarily an allergic reaction. Choice C, hormonal influences on sebaceous gland activity, is incorrect as psoriasis is not related to sebaceous gland function. Choice D, human papillomaviruses (HPV), is incorrect as HPV is not associated with psoriasis.