ATI RN
NCLEX Skin Integrity Questions Questions
Question 1 of 5
The nurse instructs a patient about application of corticosteroid cream to an area of contact dermatitis on the right leg. Which patient action indicates that further teaching is needed?
Correct Answer: C
Rationale: The correct answer is C because applying a thick layer of corticosteroid cream can lead to overuse and potential side effects such as skin thinning. The appropriate amount of cream should be applied thinly and evenly to the affected area. Choice A is correct as taking a tepid bath can help cleanse the area before application. Choice B is correct as spreading the cream in a downward motion can prevent further irritation. Choice D is incorrect as covering the area with a dressing is not recommended for corticosteroid cream application, as it can lead to increased absorption and potential side effects.
Question 2 of 5
Which finding for a 77-yr-old patient seen in the outpatient clinic requires further nursing assessment and intervention?
Correct Answer: D
Rationale: The correct answer is D because a history of recent loss of balance and fall in an elderly patient may indicate potential underlying issues such as vestibular dysfunction, neurological problems, medication side effects, or musculoskeletal issues. Further assessment and intervention are crucial to prevent future falls and ensure patient safety. A: Symmetric joint swelling of fingers is common in older adults and may be related to arthritis or other degenerative conditions, but it does not necessarily require immediate intervention. B: Decreased right knee range of motion could be due to age-related changes or arthritis, which may warrant assessment but does not pose an immediate safety risk. C: Report of left hip aching when jogging may indicate musculoskeletal issues or overuse injury, but it does not pose an immediate safety concern that requires urgent intervention.
Question 3 of 5
A patient with a fracture of the left femoral neck has Buck’s traction in place while waiting for surgery. To assess for pressure areas on the patient’s back and sacral area and to provide skin care, the nurse should
Correct Answer: C
Rationale: The correct answer is C because using a trapeze to lift the buttocks slightly allows for pressure relief on the back and sacral area without compromising the traction. A: Loosening the traction can lead to displacement of the fracture and should be avoided. B: Placing a pillow between the legs does not directly address pressure areas on the back and sacral area. D: Turning the patient partially with assistance may not provide adequate pressure relief on the back and sacral area.
Question 4 of 5
A patient who has had open reduction and internal fixation (ORIF) of a hip fracture tells the nurse he is ready to get out of bed for the first time. Which action should the nurse take?
Correct Answer: A
Rationale: The correct answer is A: Check the patient’s prescribed weight-bearing status. After ORIF of a hip fracture, weight-bearing status is crucial to prevent complications. Checking this ensures the patient follows the appropriate weight-bearing restrictions. B: Using a mechanical lift is not necessary unless the patient is non-weight bearing. C: Delegating to NAP may not ensure proper assessment of weight-bearing status. D: Decreasing pain medication before getting up may lead to increased pain and reluctance to move.
Question 5 of 5
A patient who slipped and fell in the shower at home has a proximal left humerus fracture immobilized with a long-arm cast and a sling. Which nursing intervention will be included in the plan of care?
Correct Answer: C
Rationale: The correct answer is C: Assess the left axilla and change absorbent dressings as needed. This is important to monitor for skin breakdown and infection due to the immobilization of the left arm. The axilla is a common site for pressure sores in patients with arm casts. Using surgical net dressing to hang the arm from an IV pole (A) is not appropriate as it can cause discomfort and compromise circulation. Immobilizing the fingers of the left hand with gauze dressings (B) is unnecessary and can lead to stiffness and decreased circulation. Assisting the patient in passive ROM for the right arm (D) is not directly related to the care of the left humerus fracture.