ATI LPN
NCLEX Questions Skin Integrity and Wound Care Questions
Question 1 of 5
The reason that Medicare will not pay for care for a deep vein thrombosis on a patient in the hospital after knee replacement is:
Correct Answer: B
Rationale: Medicare denies payment for preventable hospital-acquired conditions (HACs) under CMS policy. Deep vein thrombosis (DVT) post-knee replacement is an HAC if prophylaxis (e.g., anticoagulants) wasn't followed, deemed avoidable with proper care. Risk status doesn't negate prevention duty. Cost-cutting isn't specific to DVT. Private insurance isn't assumed. Preventability drives nonpayment, per CMS guidelines, making it the correct reason LPNs must ensure prophylaxis adherence.
Question 2 of 5
It is important that the nurse understand that certain cultural traits should be assessed in patients. Patients of Asian, African, and Hispanic descent should be assessed for:
Correct Answer: C
Rationale: Cultural traits influence health risks. Sickle cell anemia is prevalent in African descent (also some Hispanic, Asian groups), per genetic studies, requiring screening. Stomach cancer links to diet (e.g., Asian salted foods) but isn't universal. Retinopathy ties to diabetes, not ethnicity-specific. Lactose intolerance is common but less acute. Sickle cell's hereditary impact makes it a critical assessment, per cultural competence, making it the correct focus.
Question 3 of 5
Common sympathetic reactions to a stressor that occurs suddenly include:
Correct Answer: D
Rationale: Sudden stressors trigger the sympathetic'fight or flight' response. Pounding heart and rapid pulse occur as adrenaline boosts circulation, per physiology. Pupil constriction is parasympathetic. Saliva/tear increase opposes dry mouth from stress. Weak knees may happen but isn't universal. Heart rate elevation is a hallmark sign LPNs monitor, making this the correct and most consistent reaction.
Question 4 of 5
The nurse reinforces turning, coughing, and deep breathing to a preoperative patient. Which statement indicates a need for further instruction?
Correct Answer: B
Rationale: Turning, coughing, and deep breathing prevent pneumonia post-op.'Lying still' contradicts this immobility risks atelectasis, showing misunderstanding. Bracing with a pillow aids coughing. Pneumonia prevention is correct. Early ambulation helps, though'immediately' exaggerates. Staying still opposes respiratory clearance, needing reteaching, making it the correct statement for further instruction.
Question 5 of 5
While assessing a newly postoperative patient with temperature 104.9°F, BP 90/60, pulse 58, respirations 30, jaw rigidity, and dark urine, the priority action is:
Correct Answer: B
Rationale: These signs hyperthermia, hypotension, bradycardia, tachypnea, jaw rigidity, dark urine suggest malignant hyperthermia (MH), an anesthesia emergency. Notifying the surgeon is urgent, per MH protocols, for dantrolene administration. Relaxation or pain meds don't treat MH. Sponge bath delays critical care. Immediate reporting triggers life-saving intervention, an LPN priority, making it the correct action.