ATI RN
NCLEX Practice Questions Skin Integrity and Wound Care Questions
Question 1 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 2 of 5
The second day after admission with a fractured pelvis, a patient suddenly develops confusion. Which action should the nurse take first?
Correct Answer: A
Rationale: The correct action is to take the blood pressure first because sudden confusion in a patient with a fractured pelvis could indicate a potential medical emergency like hypotension or hemorrhage. Assessing blood pressure is crucial to rule out these life-threatening conditions promptly. Checking O2 saturation, observing for facial asymmetry, and assessing patient orientation are important assessments but not the priority in this situation. O2 saturation is important for assessing respiratory status, facial asymmetry for neurological issues, and patient orientation for cognitive function, but these can be done after ruling out immediate life-threatening conditions like hypotension.
Question 3 of 5
After change-of-shift report, which patient should the nurse assess first?
Correct Answer: D
Rationale: The correct answer is D. The nurse should assess the patient with a repaired right femoral shaft fracture complaining of tightness in the calf first. This could indicate a potential complication like deep vein thrombosis (DVT), which is a serious condition requiring immediate attention to prevent further harm. Assessing for DVT is crucial as it can lead to pulmonary embolism if left untreated. Choice A is incorrect as facial pain in a patient with a repaired mandibular fracture, while important, does not pose an immediate life-threatening risk. Choice B is incorrect as an externally rotated leg in a patient with an unrepaired intracapsular left hip fracture may indicate a hip dislocation, but it is not as urgent as assessing for a potential DVT. Choice C is incorrect as wrist swelling and deformity in a patient with an unrepaired Colles’ fracture, while concerning, does not require immediate attention compared to the potential complication of DVT in the patient with the femoral shaft
Question 4 of 5
A patient whose employment requires frequent lifting has a history of chronic back pain. After the nurse has taught the patient about correct body mechanics, which patient statement indicates the teaching has been effective?
Correct Answer: B
Rationale: The correct answer is B because the patient recognizing the importance of strengthening and supporting their back aligns with the goal of preventing further back pain. Strengthening exercises can help improve muscle support and reduce the risk of injury during lifting tasks. Choice A is incorrect as lifting above the waist with a straight back may still put strain on the back. Choice C is incorrect as avoiding lifting altogether is not a practical solution for someone whose job involves frequent lifting. Choice D is incorrect as sleeping with hips and knees extended may not necessarily prevent back strain during lifting activities.
Question 5 of 5
After laminectomy with a spinal fusion to treat a herniated disc, a patient reports numbness and tingling of the right lower leg. The first action the nurse should take is to
Correct Answer: A
Rationale: The correct answer is A: report the patient’s complaint to the surgeon. The numbness and tingling in the right lower leg could indicate nerve damage post-laminectomy with spinal fusion. It is crucial to inform the surgeon immediately to evaluate and address the issue promptly. Checking the preoperative assessment data (B) may not provide immediate insight into the current issue. Checking vital signs for hemorrhage (C) is important but not the priority in this scenario. Turning the patient to the left (D) would not address the underlying cause and could potentially worsen the symptoms. Reporting to the surgeon ensures timely intervention and prevents further complications.