ATI LPN
NCLEX Questions Skin Integrity and Wound Care Questions
Question 1 of 5
Common sympathetic reactions to a stressor that occurs suddenly include:
Correct Answer: D
Rationale: Sudden stressors trigger the sympathetic'fight or flight' response. Pounding heart and rapid pulse occur as adrenaline boosts circulation, per physiology. Pupil constriction is parasympathetic. Saliva/tear increase opposes dry mouth from stress. Weak knees may happen but isn't universal. Heart rate elevation is a hallmark sign LPNs monitor, making this the correct and most consistent reaction.
Question 2 of 5
While assessing a newly postoperative patient with temperature 104.9°F, BP 90/60, pulse 58, respirations 30, jaw rigidity, and dark urine, the priority action is:
Correct Answer: B
Rationale: These signs hyperthermia, hypotension, bradycardia, tachypnea, jaw rigidity, dark urine suggest malignant hyperthermia (MH), an anesthesia emergency. Notifying the surgeon is urgent, per MH protocols, for dantrolene administration. Relaxation or pain meds don't treat MH. Sponge bath delays critical care. Immediate reporting triggers life-saving intervention, an LPN priority, making it the correct action.
Question 3 of 5
Which measure would be appropriate when caring for a postoperative patient with a bulb suction wound drain?
Correct Answer: C
Rationale: Bulb suction (e.g., Jackson-Pratt) removes fluid. Compressing the bulb restores suction, per surgical care, preventing fluid buildup. Assessing patency and measuring drainage are key but ongoing. Rinsing with sterile water risks contamination not standard. Compression maintains function, an LPN duty, making it the correct and most immediate action.
Question 4 of 5
You are observing a nursing student perform a dressing change. You would intervene if the student:
Correct Answer: D
Rationale: Dressing changes balance sterility and practicality. Using sterile gloves to remove old dressing is incorrect clean gloves suffice, per infection control, reserving sterile for new application. Gathering supplies (Choice A), identifying patient (Choice B), and hand hygiene with clean gloves are standard. Sterile removal wastes resources and risks contamination later, needing intervention, making it the correct action.
Question 5 of 5
You administer ketorolac 30 mg IM. The gate control theory indicates the next action to assist in pain control would be to:
Correct Answer: D
Rationale: Gate control theory posits non-pain stimuli block pain signals. Encouraging distraction e.g., music enhances ketorolac's effect, per pain management. Recapping is safety, not pain-related. Massaging may worsen IM irritation. Checking later assesses, doesn't aid. Distraction leverages theory, an LPN adjunct, making it the correct next action.