ATI LPN
NCLEX Style Questions on Skin Integrity and Wound Care Questions
Question 1 of 5
The nurse is caring for a client who has had spinal fusion, with insertion of hardware. The nurse would be most concerned with which assessment finding?
Correct Answer: A
Rationale: A fever of 101.6°F suggests a possible postoperative infection, a serious complication after spinal fusion with hardware, requiring immediate attention.
Question 2 of 5
Which situation makes the nurse suspect the client has glaucoma?
Correct Answer: A
Rationale: Glaucoma causes peripheral vision loss, which could prevent seeing a car in the next lane, leading to an accident, aligning with its typical presentation.
Question 3 of 5
The PACU nurse administers Narcan, an opioid antagonist, to a postoperative client. Which client problem should the nurse include to the plan of care based on this medication?
Correct Answer: B
Rationale: Narcan reverses opioid-induced respiratory depression, highlighting the risk for respiratory complications.
Question 4 of 5
Which laboratory value should be monitored by the nurse for the client diagnosed with diabetes insipidus?
Correct Answer: A
Rationale: Diabetes insipidus causes dilute urine and hypernatremia; serum sodium monitoring is key.
Question 5 of 5
A client with myocardial infarction suddenly becomes tachycardic, shows signs of air hunger, and begins coughing frothy, pink-tinged sputum. Which finding would the nurse anticipate when auscultating the client's breath sounds?
Correct Answer: B
Rationale: Pulmonary edema from MI causes crackles due to fluid in the alveoli.