ATI RN
NCLEX Skin Integrity Questions Questions
Question 1 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 2 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.
Question 3 of 5
Which assessment finding for a patient who has had surgical reduction of an open fracture of the right radius requires notification of the health care provider?
Correct Answer: D
Rationale: The correct answer is D because a temperature of 101.4°F indicates possible infection post-surgery, requiring immediate notification of the healthcare provider for further evaluation and treatment. Elevated temperature can indicate systemic infection. A: Serous wound drainage is expected post-surgery and not concerning. B: Right arm pain with movement is typical after surgical reduction and should be managed with pain medication. C: Right arm muscle spasms can be a normal response to surgery and may resolve with proper rest and care.
Question 4 of 5
A nurse is teaching a patient with contact dermatitis of the arms and legs about ways to decrease pruritus. Which information should the nurse include in the teaching plan(select the one that does not apply)?
Correct Answer: C
Rationale: The correct answer is C. Adding oil to bath water can exacerbate contact dermatitis by further irritating the skin. Oil can create a barrier that traps irritants and moisture, worsening symptoms. The other options are appropriate for managing pruritus in contact dermatitis. A: Cool, wet cloths or compresses can provide relief by soothing and reducing inflammation. B: Cool or tepid baths help to soothe the skin and reduce itching. D: Rubbing dry with a towel after bathing helps prevent skin maceration and further irritation. Adding oil to bath water is contra-indicated in contact dermatitis management.
Question 5 of 5
Atopic dermatitis can be described as: Select all that apply.
Correct Answer: B
Rationale: Atopic dermatitis is characterized by oozing due to the disrupted skin barrier. Vesicle formation is more characteristic of allergic contact dermatitis. Round, erythematous papules that enlarge and coalesce are seen in nummular eczema. Raised wheals with associated itching are typical of urticaria. Oozing is specific to atopic dermatitis due to impaired skin barrier function.