ATI RN
NCLEX Practice Questions Skin Integrity and Wound Care Questions
Question 1 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 2 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 3 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.
Question 4 of 5
Which actions will the nurse include in the plan of care for a patient with metastatic bone cancer of the left femur(select the one that does not apply)?
Correct Answer: C
Rationale: The correct answer is C because discontinuing the use of sustained-release opioids is not appropriate for a patient with metastatic bone cancer of the left femur. This patient likely experiences severe pain that requires opioids for adequate pain management. Monitoring serum calcium levels (A) is essential due to the risk of hypercalcemia. Teaching about the need for strict bed rest (B) helps prevent fractures and reduces pain. Supporting the left leg when repositioning the patient (D) helps maintain alignment and prevent further damage.
Question 5 of 5
A client has been admitted to the intensive care unit of the hospital after developing toxic epidermal necrolysis (TEN) consequent to the administration of a sulfonamide antibiotic. What pathophysiologic phenomenon is likely the greatest immediate threat to this client's health?
Correct Answer: D
Rationale: The correct answer is D. The presence of diffuse lesions and skin sloughing on the client's mucous membranes is the greatest immediate threat in toxic epidermal necrolysis (TEN). This condition results in severe skin detachment, leading to increased risk of infection, fluid loss, and electrolyte imbalances. Skin sloughing can also affect mucous membranes, increasing the risk of respiratory compromise, sepsis, and systemic infection. The other choices are not the greatest immediate threat in TEN. Bacterial cellulitis (choice A) is a potential complication but not the most immediate threat. Fluid and electrolyte imbalances (choice B) are significant but secondary to the skin sloughing. A cascading autoimmune response (choice C) can occur in TEN but is not the immediate threat compared to the risk of mucous membrane involvement and skin sloughing.