ATI RN
Skin Integrity and Wound Care NCLEX Questions Questions
Question 1 of 5
After completing the health history, the nurse assessing the musculoskeletal system will begin by
Correct Answer: C
Rationale: The correct answer is C because observing the patient's body build and muscle configuration provides initial information about the patient's overall musculoskeletal health. This step allows the nurse to assess for any abnormalities, such as muscle atrophy or asymmetry, which can indicate underlying musculoskeletal issues. It also helps in identifying any deformities or structural abnormalities. Choice A is incorrect because having the patient move the extremities against resistance comes later in the assessment process to evaluate muscle strength. Choice B is incorrect as feeling for crepitus during joint movement is a specific assessment for joint health and does not address the overall musculoskeletal system. Choice D is incorrect as checking active and passive range of motion for the extremities is typically done after observing the patient's body build and muscle configuration.
Question 2 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 3 of 5
Which statement by a patient who has had an above-the-knee amputation indicates the nurse’s discharge teaching has been effective?
Correct Answer: B
Rationale: The correct answer is B because lying flat on the abdomen helps prevent hip flexion contractures after an above-the-knee amputation. This position stretches the hip flexors and prevents shortening of these muscles, maintaining flexibility. It also facilitates proper alignment of the residual limb, reducing the risk of contractures. Choices A, C, and D are incorrect. A: Elevating the residual limb on a pillow is not the most effective way to prevent contractures. C: Changing the limb sock is important for hygiene but not directly related to preventing contractures. D: Using lotion on the stump is beneficial for skin care but does not address the prevention of contractures.
Question 4 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 5 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.