ATI RN
Skin Integrity and Wound Care NCLEX Questions Questions
Question 1 of 5
A patient who is to have no weight bearing on the left leg is learning to walk using crutches. Which observation by the nurse indicates the patient can safely ambulate independently?
Correct Answer: B
Rationale: The correct answer is B because it demonstrates proper crutch walking technique. By advancing the left leg and both crutches together first, the patient maintains non-weight bearing on the left leg. Then, advancing the right leg allows for a smooth and balanced gait pattern. Choice A is incorrect because it would result in weight-bearing on the left leg when the right crutch is moved with the right leg. Choice C is incorrect as the patient should not rely on external support like a bedside chair for balance during ambulation. Choice D is incorrect as the crutch should not be placed firmly in the axillary area to avoid nerve damage.
Question 2 of 5
A young adult arrives in the emergency department with ankle swelling and severe pain after twisting an ankle playing basketball. Which of these prescribed interprofessional interventions will the nurse implement first?
Correct Answer: B
Rationale: The correct answer is B: Wrap the ankle and apply an ice pack. This intervention addresses immediate pain management and inflammation control, crucial in the initial management of an ankle injury. Wrapping the ankle helps stabilize it, while applying an ice pack reduces swelling and provides pain relief. X-rays (A) are important for diagnosing fractures but are not the first priority. Administering naproxen (C) or acetaminophen with codeine (D) can help with pain relief, but they are not as immediate as applying ice and wrapping the ankle. Ice and compression are the first-line interventions in acute ankle injuries.
Question 3 of 5
Before assisting a patient with ambulation 2 days after total hip arthroplasty, which action is most important for the nurse to take?
Correct Answer: B
Rationale: The correct answer is B, administer prescribed pain medication, as it ensures the patient's comfort and enables safe ambulation post-total hip arthroplasty. Pain management is crucial for successful ambulation and overall recovery. Observing output from the surgical drain (A) is important but not the priority at this time. Instructing the patient about the benefits of early ambulation (C) is essential but should come after pain management. Changing the dressing and documenting the wound appearance (D) is necessary but can be done after addressing the patient's pain.
Question 4 of 5
A patient with acute osteomyelitis of the left femur is hospitalized for regional antibiotic irrigation. Which intervention will the nurse include in the initial plan of care?
Correct Answer: B
Rationale: The correct answer is B: Immobilization of the left leg. In acute osteomyelitis, immobilization of the affected limb helps reduce movement and prevent further damage or spread of infection. Immobilization also promotes healing and allows for effective administration of regional antibiotic irrigation. Quadriceps-setting exercises (choice A) may be considered later in the treatment plan to prevent muscle atrophy but are not appropriate initially. Positioning the left leg in flexion (choice C) can worsen the infection by limiting circulation and exacerbating pain. Assisted weight-bearing ambulation (choice D) can increase pressure on the affected bone and hinder healing.
Question 5 of 5
An assessment finding for a 55-yr-old patient that alerts the nurse to the presence of osteoporosis is
Correct Answer: B
Rationale: The correct answer is B: a loss of height. Osteoporosis is characterized by decreased bone density, leading to a loss of height due to compression fractures in the spine. Bowed legs (choice A) are not typically associated with osteoporosis. The report of frequent falls (choice C) may indicate balance issues but is not specific to osteoporosis. An aversion to dairy products (choice D) may lead to a lack of calcium intake, but it is not a direct assessment finding for osteoporosis. Therefore, the presence of a loss of height is the most indicative assessment finding for osteoporosis in a 55-year-old patient.