ATI LPN
NCLEX Style Questions on Skin Integrity and Wound Care Questions
Question 1 of 5
The nurse is working on an orthopedic floor. Which client should the nurse assess first after the change-of-shift report?
Correct Answer: B
Rationale: Confusion in a post-TKR patient may indicate delirium or hypoxia, requiring urgent assessment.
Question 2 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 3 of 5
The nurse is administering eyedrops to the client. Which guideline should the nurse adhere to when instilling the drops into the eye?
Correct Answer: C
Rationale: The original multiple-answer question is restructured. Holding the lower lid down and instilling drops into the conjunctiva (from option 4) avoids corneal irritation and ensures proper absorption.
Question 4 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 5 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.