ATI RN
Fundamentals of Nursing Skin Integrity Questions Questions
Question 1 of 5
The nurse notes crackling sounds and a grating sensation with palpation of an older patient’s elbow. How will this finding be documented?
Correct Answer: B
Rationale: The correct answer is B: Crepitation. Crepitation refers to crackling sounds and a grating sensation felt with palpation, often indicative of joint or bone abnormalities. It is commonly associated with osteoarthritis or joint degeneration, which is common in older patients. Torticollis (A) is a condition characterized by abnormal neck positioning, not related to elbow findings. Subluxation (C) refers to partial dislocation of a joint, not typically associated with crackling sounds. Epicondylitis (D) is inflammation of the tendons attached to the elbow, but it does not involve crackling sounds or a grating sensation.
Question 2 of 5
A patient with a right lower leg fracture will be discharged home with an external fixation device in place. Which information will the nurse teach?
Correct Answer: A
Rationale: The correct answer is A: Check and clean the pin insertion sites daily. This is important to prevent infection, which is a common complication with external fixation devices. Cleaning the pin sites reduces the risk of infection and promotes healing. Summary of other choices: B: Removing the external fixator for showering can compromise the stability of the fracture. C: Remaining on bed rest until bone healing is complete is not necessary and can lead to complications like muscle atrophy. D: Taking prophylactic antibiotics until the fixator is removed is not recommended unless there is a specific indication for infection prevention.
Question 3 of 5
When giving home care instructions to a patient who has comminuted left forearm fractures and a long-arm cast, which information should the nurse include?
Correct Answer: C
Rationale: The correct answer is C: Call the health care provider for numbness of the hand. In a patient with comminuted left forearm fractures and a long-arm cast, numbness could indicate compartment syndrome, a serious complication. Prompt intervention is crucial to prevent tissue damage. Keeping the shoulder elevated (A) is important for comfort but not directly related to the fractures. Avoiding NSAIDs (B) is generally recommended for fractures due to their potential to delay healing. Keeping the hand immobile (D) is important, but it does not address the potential emergency situation of developing compartment syndrome.
Question 4 of 5
A pedestrian who was hit by a car is admitted to the emergency department with possible right lower leg fractures. The initial action by the nurse should be to
Correct Answer: C
Rationale: The correct initial action by the nurse in this scenario is to assess the pedal pulses (Choice C). This is crucial to determine the circulation and perfusion status of the injured limb. If the pedal pulses are absent or weak, it indicates compromised blood flow, which is a medical emergency requiring immediate intervention. Elevating the right leg (Choice A) may worsen circulation if pulses are weak. Splinting the lower leg (Choice B) should only be done after assessing the pulses. Verifying tetanus immunization (Choice D) is important but not the immediate priority in this situation.
Question 5 of 5
Which information obtained by the nurse about a patient with a lumbar vertebral compression fracture requires an immediate report to the health care provider?
Correct Answer: B
Rationale: Correct Answer: B Rationale: 1. Incontinence of urine and stool indicates potential spinal cord injury or nerve compression, requiring immediate evaluation. 2. Choice A is important but does not indicate a life-threatening condition. 3. Choice C is expected with a lumbar vertebral compression fracture and can be managed conservatively. 4. Choice D is relevant for long-term management but does not require immediate intervention.