ATI RN
NCLEX Questions Skin Integrity and Wound Care Questions
Question 1 of 5
The nurse finds that a patient can flex the arms when no resistance is applied but is unable to flex when the nurse applies light resistance. The nurse should document the patient’s muscle strength as level
Correct Answer: C
Rationale: The correct answer is C (2). This patient demonstrates muscle strength that is graded as 2 according to the Medical Research Council (MRC) scale. A score of 2 indicates that the patient can move the joint against gravity but not against resistance. Choices A, B, and D are incorrect because they represent different levels of muscle strength based on the MRC scale. Choice A (0) indicates no muscle contraction, choice B (1) indicates a flicker or trace of contraction, and choice D (3) indicates movement against gravity but not against resistance. Therefore, the best description of the patient's muscle strength in this scenario is level 2.
Question 2 of 5
Which statement by the patient indicates a good understanding of the nurse’s teaching about a new short-arm synthetic cast?
Correct Answer: C
Rationale: The correct answer is C because applying an ice pack to the cast over the fracture site helps reduce swelling and pain, promoting healing. This technique is commonly recommended for managing acute injuries. It shows the patient understands the importance of managing swelling in the initial phase of injury recovery. A is incorrect because getting the cast wet can weaken it and lead to skin irritation. B is incorrect as moving fingers and elbow can disrupt the healing process and cause complications. D is incorrect because applying lotion under the cast can create moisture buildup, leading to skin issues and discomfort.
Question 3 of 5
The day after a having a right below-the-knee amputation, a patient complains of pain in the missing right foot. Which action is most important for the nurse to take?
Correct Answer: B
Rationale: The correct answer is B because administering prescribed analgesics is the most important action to address the patient's pain. The pain experienced is known as phantom limb pain, which is common after amputations. Analgesics can help manage the pain effectively. Choice A is not as crucial as providing immediate pain relief. Choice C focuses on alignment rather than pain management. Choice D, while providing reassurance, does not address the immediate need for pain relief.
Question 4 of 5
A patient arrived at the emergency department after tripping over a rug and falling at home. Which finding is most important for the nurse to communicate to the health care provider?
Correct Answer: C
Rationale: The correct answer is C: The right arm appears shorter than the left. This finding suggests a possible shoulder dislocation or fracture, which requires immediate medical attention to prevent further complications. Shortening of the affected limb is a classic sign of a fracture or dislocation. Communicating this to the healthcare provider promptly can expedite appropriate treatment. Incorrect choices: A: There is bruising at the shoulder area - Bruising alone may not indicate a serious injury compared to limb shortening. B: The patient reports arm and shoulder pain - Pain is a common symptom after a fall and may not indicate a specific serious injury. D: There is decreased shoulder range of motion - While decreased range of motion is concerning, limb shortening is a more critical finding indicating a structural injury.
Question 5 of 5
A patient undergoes left above-the-knee amputation with an immediate prosthetic fitting. When the patient arrives on the orthopedic unit after surgery, the nurse should
Correct Answer: A
Rationale: The correct answer is A: assess the surgical site for hemorrhage. After an above-the-knee amputation, assessing the surgical site for hemorrhage is crucial as it helps in early detection and management of any bleeding, which can be life-threatening. Other choices are incorrect: B is wrong as removing the prosthesis can disrupt wound healing; C is incorrect as it doesn't address the immediate post-op concern of hemorrhage; D is incorrect as keeping the residual limb elevated on a pillow may not be the priority over assessing for hemorrhage.