ATI LPN
NCLEX Skin Integrity Questions Questions
Question 1 of 5
For a client with unrelieved pain after cervical neck injury, which alternative method of pain control is an independent nursing action?
Correct Answer: C
Rationale: Distraction techniques such as watching TV or listening to music are independent nursing actions for pain control.
Question 2 of 5
What intervention should the nurse implement first for a client with an injury to the left arm?
Correct Answer: A
Rationale: Capillary refill assessment evaluates circulation and potential vascular compromise.
Question 3 of 5
The nurse is assessing the client who is postoperative total knee replacement. Which assessment data warrant immediate intervention?
Correct Answer: B
Rationale: Pain during dorsiflexion (positive Homans' sign) suggests a deep vein thrombosis, a critical complication.
Question 4 of 5
A client recovering from a total hip replacement has developed a deep vein thrombosis. The health-care provider has ordered a continuous infusion of heparin, an anticoagulant, to infuse at 1,200 units per hour. The bag comes with 20,000 units of heparin in 500 mL of 0.9% normal saline. At what rate should the nurse set the pump?
Correct Answer: B
Rationale: Calculation: (1,200 units/hr × 500 mL) / 20,000 units = 30 mL/hr, the correct infusion rate.
Question 5 of 5
A client is complaining of low back pain that radiates down the left posterior thigh. The nurse should ask the client if the pain is worsened or aggravated by which factor?
Correct Answer: C
Rationale: Bending or lifting can exacerbate low back pain radiating down the leg, often indicative of sciatica or a herniated disc, as these activities increase pressure on the affected nerve roots.