ATI RN
NCLEX Skin Integrity Questions Questions
Question 1 of 5
A patient with a fracture of the left femoral neck has Buck’s traction in place while waiting for surgery. To assess for pressure areas on the patient’s back and sacral area and to provide skin care, the nurse should
Correct Answer: C
Rationale: The correct answer is C because using a trapeze to lift the buttocks slightly allows for pressure relief on the back and sacral area without compromising the traction. A: Loosening the traction can lead to displacement of the fracture and should be avoided. B: Placing a pillow between the legs does not directly address pressure areas on the back and sacral area. D: Turning the patient partially with assistance may not provide adequate pressure relief on the back and sacral area.
Question 2 of 5
A patient who slipped and fell in the shower at home has a proximal left humerus fracture immobilized with a long-arm cast and a sling. Which nursing intervention will be included in the plan of care?
Correct Answer: C
Rationale: The correct answer is C: Assess the left axilla and change absorbent dressings as needed. This is important to monitor for skin breakdown and infection due to the immobilization of the left arm. The axilla is a common site for pressure sores in patients with arm casts. Using surgical net dressing to hang the arm from an IV pole (A) is not appropriate as it can cause discomfort and compromise circulation. Immobilizing the fingers of the left hand with gauze dressings (B) is unnecessary and can lead to stiffness and decreased circulation. Assisting the patient in passive ROM for the right arm (D) is not directly related to the care of the left humerus fracture.
Question 3 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 4 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 5 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.