ATI RN
NCLEX Skin Integrity Questions Questions
Question 1 of 5
A patient who has had open reduction and internal fixation (ORIF) of a hip fracture tells the nurse he is ready to get out of bed for the first time. Which action should the nurse take?
Correct Answer: A
Rationale: The correct answer is A: Check the patient’s prescribed weight-bearing status. After ORIF of a hip fracture, weight-bearing status is crucial to prevent complications. Checking this ensures the patient follows the appropriate weight-bearing restrictions. B: Using a mechanical lift is not necessary unless the patient is non-weight bearing. C: Delegating to NAP may not ensure proper assessment of weight-bearing status. D: Decreasing pain medication before getting up may lead to increased pain and reluctance to move.
Question 2 of 5
The day after a 60-yr-old patient has open reduction and internal fixation (ORIF) for an open, displaced tibial fracture, the nurse identifies the priority nursing diagnosis as
Correct Answer: D
Rationale: Rationale for Correct Answer (D): The priority nursing diagnosis is "risk for infection related to disruption of skin integrity" because the patient underwent ORIF for an open tibial fracture, which increases the risk of infection due to the disruption of skin integrity. Post-surgery, there is a higher susceptibility to infection, which can lead to serious complications and delayed healing. Monitoring for signs of infection and implementing appropriate interventions is crucial to prevent further complications. Summary of Incorrect Choices: A: Activity intolerance is not the priority as the patient is not likely to be ambulating immediately after ORIF for a tibial fracture. B: Risk for constipation is not the priority as it is not directly related to the surgical procedure and can be managed with appropriate interventions. C: Risk for impaired skin integrity is not the priority as the main concern post-ORIF is infection due to the open fracture, which takes precedence.
Question 3 of 5
When a patient arrives in the emergency department with a facial fracture, which action will the nurse take first?
Correct Answer: D
Rationale: The correct answer is D: Check the patient’s alertness and orientation. This is the priority because it assesses the patient's level of consciousness and neurological status, which is crucial in determining the severity of the facial fracture and any potential associated injuries. Assessing alertness and orientation helps in identifying any signs of head trauma or neurological deficits. This initial assessment guides further interventions and ensures timely and appropriate care. Incorrect choices: A: Assess for nasal bleeding and pain - This is important but assessing the patient's alertness and orientation takes precedence. B: Apply ice to the face to reduce swelling - While this can be helpful later, it is not the first priority in a patient with a facial fracture. C: Use a cervical collar to stabilize the spine - Stabilizing the spine is important in trauma, but in this scenario, assessing the patient's alertness and orientation is more critical.
Question 4 of 5
An appropriate nursing intervention for a patient who has acute low back pain and muscle spasms is to teach the patient to
Correct Answer: C
Rationale: The correct answer is C because keeping the head elevated slightly and flexing the knees when resting in bed helps to reduce pressure on the lower back, promoting relaxation of the muscles and reducing muscle spasms. Elevating the head slightly can also help maintain proper spinal alignment. Choice A is incorrect because keeping both feet flat on the floor when prolonged standing is required may not directly address the low back pain and muscle spasms. Choice B is incorrect because twisting gently from side to side can aggravate the muscle spasms and strain the lower back muscles further. Choice D is incorrect because cold packs can actually help reduce muscle spasms and inflammation, so avoiding their use would not be beneficial for managing acute low back pain and muscle spasms.
Question 5 of 5
Which assessment finding for a patient who has had surgical reduction of an open fracture of the right radius requires notification of the health care provider?
Correct Answer: D
Rationale: The correct answer is D because a temperature of 101.4°F indicates possible infection post-surgery, requiring immediate notification of the healthcare provider for further evaluation and treatment. Elevated temperature can indicate systemic infection. A: Serous wound drainage is expected post-surgery and not concerning. B: Right arm pain with movement is typical after surgical reduction and should be managed with pain medication. C: Right arm muscle spasms can be a normal response to surgery and may resolve with proper rest and care.