ATI RN
Skin Integrity and Wound Care NCLEX Questions Quizlet Questions
Question 1 of 5
A patient who has had open reduction and internal fixation (ORIF) of left lower leg fractures continues to complain of severe pain in the leg 15 minutes after receiving the prescribed IV morphine. Pulses are faintly palpable and the foot is cool to the touch. Which action should the nurse take next?
Correct Answer: A
Rationale: The correct answer is A: Notify the health care provider. In this scenario, the patient's severe pain, faint pulses, and cool foot suggest a potential complication such as compartment syndrome, which is a medical emergency. Notifying the health care provider immediately is crucial for prompt evaluation and intervention to prevent further complications. Repositioning the leg on pillows (choice C) may worsen the condition, assessing the incision for redness (choice B) is not the priority in this situation, and checking the patient's blood pressure (choice D) does not directly address the urgent issue at hand.
Question 2 of 5
Which nursing action for a patient who has had right hip arthroplasty can the nurse delegate to experienced unlicensed assistive personnel (UAP)?
Correct Answer: A
Rationale: The correct answer is A: Reposition the patient every 1 to 2 hours. This task can be safely delegated to experienced UAP as it involves a routine activity to prevent pressure ulcers and maintain circulation. UAPs are trained and competent in repositioning techniques. Repositioning is crucial after hip arthroplasty to prevent complications like pressure ulcers and deep vein thrombosis. Other Choices: B: Assess for skin irritation on the patient’s back - This requires nursing assessment and critical thinking skills. UAPs are not qualified to assess for skin issues. C: Teach the patient quadriceps-setting exercises - This involves patient education and requires nursing knowledge. UAPs should not provide patient education. D: Determine the patient’s pain intensity and tolerance - Pain assessment is a nursing responsibility that requires clinical judgment and expertise. UAPs should not assess or determine pain levels.
Question 3 of 5
When assessing for Tinel’s sign in a patient with possible right carpal tunnel syndrome, the nurse will ask the patient about
Correct Answer: D
Rationale: The correct answer is D because Tinel's sign in carpal tunnel syndrome manifests as tingling in the thumb and index finger due to compression of the median nerve. This occurs when tapping over the carpal tunnel elicits tingling or pins and needles sensation. Weakness in the right little finger (A), burning in the right elbow and forearm (B), and tremor when gripping with the right hand (C) are not typically associated with Tinel's sign or specific to carpal tunnel syndrome.
Question 4 of 5
A patient is being discharged after 1 week of IV antibiotic therapy for acute osteomyelitis in the right leg. Which information will be included in the discharge teaching?
Correct Answer: B
Rationale: The correct answer is B: How to monitor and care for a long-term IV catheter. This is crucial as the patient may require ongoing IV antibiotics after discharge. Proper care can prevent infections and complications. Warm packs (choice A) may not be recommended for osteomyelitis. Daily aerobic exercise (choice C) is not directly related to IV antibiotic therapy. Taking oral antibiotics post-discharge (choice D) is not the focus of IV catheter care.
Question 5 of 5
A 54-yr-old woman who recently reached menopause and has a family history of osteoporosis is diagnosed with osteopenia following densitometry testing. In teaching the woman, the nurse explains that
Correct Answer: D
Rationale: The correct answer is D. Increasing calcium intake and weight-bearing exercise can help slow calcium loss from bones, which is crucial in managing osteopenia and preventing progression to osteoporosis. Calcium is essential for bone health, and weight-bearing exercises help strengthen bones. A: Incorrect. Family history of osteoporosis does not mean it cannot be prevented or slowed down. Lifestyle modifications can help manage the condition. B: Incorrect. Estrogen replacement therapy is not the only option for managing osteopenia. It may have risks and benefits that should be discussed with a healthcare provider. C: Incorrect. Corticosteroid treatment is not typically recommended for osteopenia or osteoporosis management. It can have adverse effects on bone health.