ATI LPN
NCLEX Questions Skin Integrity and Wound Care Questions
Question 1 of 5
It is important that the nurse understand that certain cultural traits should be assessed in patients. Patients of Asian, African, and Hispanic descent should be assessed for:
Correct Answer: C
Rationale: Cultural traits influence health risks. Sickle cell anemia is prevalent in African descent (also some Hispanic, Asian groups), per genetic studies, requiring screening. Stomach cancer links to diet (e.g., Asian salted foods) but isn't universal. Retinopathy ties to diabetes, not ethnicity-specific. Lactose intolerance is common but less acute. Sickle cell's hereditary impact makes it a critical assessment, per cultural competence, making it the correct focus.
Question 2 of 5
The nurse reinforces turning, coughing, and deep breathing to a preoperative patient. Which statement indicates a need for further instruction?
Correct Answer: B
Rationale: Turning, coughing, and deep breathing prevent pneumonia post-op.'Lying still' contradicts this immobility risks atelectasis, showing misunderstanding. Bracing with a pillow aids coughing. Pneumonia prevention is correct. Early ambulation helps, though'immediately' exaggerates. Staying still opposes respiratory clearance, needing reteaching, making it the correct statement for further instruction.
Question 3 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 4 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 5 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.