ATI RN
NCLEX Questions on Skin Integrity and Wound Care Questions
Question 1 of 5
The nurse assesses a patient who has just arrived in the post-anesthesia recovery area (PACU) after a blepharoplasty. Which assessment data should be reported to the surgeon immediately?
Correct Answer: C
Rationale: The correct answer is C because the inability to detect when the eyelids are touched may indicate nerve damage, which is a critical post-operative complication following a blepharoplasty. This should be reported immediately to the surgeon for prompt evaluation and intervention to prevent further complications. Choice A is incorrect because incisional pain is expected after surgery and can be managed with pain relief medications. Choice B, a heart rate of 110 beats/min, is elevated but not an immediate concern unless other symptoms are present. Choice D, pale and cold skin around the incision, may indicate poor circulation but is not as urgent as nerve damage in this context.
Question 2 of 5
Which action can the nurse delegate to unlicensed assistive personnel (UAP) who are working in the orthopedic clinic?
Correct Answer: B
Rationale: The correct answer is B. UAP can safely obtain a blood sample for uric acid from a patient with gout as it is a non-invasive task that does not require specialized nursing knowledge. The rationale includes: 1. UAP training often includes basic phlebotomy skills. 2. Blood sample collection is a routine task that can be delegated. 3. Uric acid testing is a common diagnostic procedure for gout. Other choices require higher-level nursing assessment and intervention skills, which UAP are not trained or qualified to perform. A: Assessing muscle strength requires nursing judgment. C: Performing straight-leg-raise testing involves potential risk of injury. D: Checking for knee crepitation before surgery requires specific knowledge and expertise.
Question 3 of 5
A patient has a long-arm plaster cast applied for fracture immobilization. Until the cast has completely dried, the nurse should
Correct Answer: B
Rationale: The correct answer is B: avoid handling the cast using fingertips. This is because handling the cast while it is still wet can deform or break it, leading to improper immobilization. It is crucial to allow the cast to dry completely to ensure proper support and healing of the fracture. Keeping the arm in a dependent position (choice A) is not necessary for the drying process. Placing gauze around the cast edge (choice C) may interfere with the drying process and cause uneven drying. Covering the cast with a blanket (choice D) may trap moisture and prolong the drying time, leading to potential complications.
Question 4 of 5
After the health care provider recommends amputation for a patient who has nonhealing ischemic foot ulcers, the patient tells the nurse that he would rather die than have an amputation. Which response by the nurse is best?
Correct Answer: C
Rationale: The correct answer is C because it demonstrates active listening and allows the nurse to assess the patient's understanding and concerns about the treatment options. By asking the patient to share what they know, the nurse can address any misconceptions, provide additional information, and involve the patient in decision-making. Choice A is incorrect because it dismisses the patient's feelings and does not address the patient's concerns. Choice B is incorrect because it assumes the patient will be open to using a foot prosthesis without exploring the patient's preferences further. Choice D is incorrect because it does not address the patient's need for information and support in making an informed decision about their treatment options.
Question 5 of 5
After being hospitalized for 3 days with a right femur fracture, a patient suddenly develops shortness of breath and tachypnea. The patient tells the nurse, 'I feel like I am going to die!' Which action should the nurse take first?
Correct Answer: B
Rationale: The correct action for the nurse to take first is to administer prescribed PRN O2 at 4 L/min (Choice B). This is the correct choice because the patient is showing signs of respiratory distress, which could indicate a pulmonary embolism, a potentially life-threatening complication following a femur fracture. Administering oxygen can help improve oxygenation and stabilize the patient's condition. It is essential to address the immediate physiological need for oxygen before taking further action. Staying with the patient and offering reassurance (Choice A) may be important but addressing the respiratory distress is the priority. Checking the patient's legs for swelling or tenderness (Choice C) may help in assessing for a potential deep vein thrombosis, but it is not the most urgent action in this scenario. Notifying the health care provider (Choice D) can be done after stabilizing the patient's condition with oxygen.