ATI RN
NCLEX Practice Questions Skin Integrity and Wound Care Questions
Question 1 of 5
The nurse is caring for a patient diagnosed with furunculosis. Which nursing action could the nurse delegate to unlicensed assistive personnel (UAP)?
Correct Answer: D
Rationale: The correct answer is D because cleaning the skin with antimicrobial soap is a task that can be safely delegated to UAP. This task does not require specialized nursing knowledge or assessment skills. It is within the scope of practice for UAP and is important in preventing the spread of infection. Applying antibiotic cream (choice A) and obtaining cultures (choice B) require specific nursing assessments and skills. Evaluating personal hygiene (choice C) involves assessment and critical thinking, which are beyond the scope of practice for UAP.
Question 2 of 5
Which finding from analysis of fluid from a patient’s right knee arthrocentesis will be of concern to the nurse?
Correct Answer: A
Rationale: The correct answer is A: Cloudy fluid. Cloudy fluid from knee arthrocentesis indicates the presence of infection or inflammation, which can be concerning for the nurse. This finding suggests the presence of pus, white blood cells, or microorganisms in the fluid, indicating a possible septic joint. Scant thin fluid (B) is not concerning as it may indicate a non-inflammatory condition. Pale yellow (C) and straw-colored (D) fluids are normal findings in arthrocentesis and do not raise concerns for infection or inflammation.
Question 3 of 5
Which nursing intervention will be included in the plan of care after a patient with a right femur fracture has a hip spica cast applied?
Correct Answer: B
Rationale: The correct answer is B: Ask the patient about abdominal discomfort. This is important because the patient with a hip spica cast may experience pressure on the abdomen, leading to potential abdominal discomfort or complications. It is crucial to monitor for signs of abdominal issues promptly. A: Avoid placing the patient in prone position - While this is generally a good practice to prevent pressure ulcers, it is not directly related to the specific concern of abdominal discomfort in this scenario. C: Discuss remaining on bed rest for several weeks - While bed rest may be necessary for a period, it is not directly addressing the potential issue of abdominal discomfort from the spica cast. D: Use the cast support bar to reposition the patient - While repositioning the patient is important, the primary concern in this situation is monitoring for abdominal discomfort, not repositioning the patient.
Question 4 of 5
The nurse’s discharge teaching for a patient who has had a repair of a fractured mandible will include information about
Correct Answer: B
Rationale: The correct answer is B: how and when to cut the immobilizing wires. This is crucial information for the patient post-repair of a fractured mandible to ensure safe removal of the immobilizing wires as per the surgeon's instructions. Cutting them incorrectly can lead to complications or injury. A: Administration of nasogastric tube feedings is not directly related to the patient's mandible fracture repair. C: While high-fiber foods may be important for overall health, it is not specifically related to the immediate postoperative care of a fractured mandible. D: The use of sterile technique for dressing changes is important for wound care but is not directly related to the immobilizing wires for a fractured mandible.
Question 5 of 5
A patient is being discharged 4 days after hip arthroplasty using the posterior approach. Which patient action requires intervention by the nurse?
Correct Answer: B
Rationale: The correct answer is B because leaning over to pull on shoes and socks can put excessive strain on the hip joint, potentially leading to dislocation or injury post-hip arthroplasty. This action should be avoided to prevent complications. The other choices (A, C, D) are safe post-hip arthroplasty actions that promote proper weight-bearing, mobility, and independence without risking injury or dislocation.