ATI LPN
NCLEX Skin Integrity Questions Questions
Question 1 of 5
What intervention should the nurse implement first for a client with an injury to the left arm?
Correct Answer: A
Rationale: Capillary refill assessment evaluates circulation and potential vascular compromise.
Question 2 of 5
A client recovering from a total hip replacement has developed a deep vein thrombosis. The health-care provider has ordered a continuous infusion of heparin, an anticoagulant, to infuse at 1,200 units per hour. The bag comes with 20,000 units of heparin in 500 mL of 0.9% normal saline. At what rate should the nurse set the pump?
Correct Answer: B
Rationale: Calculation: (1,200 units/hr × 500 mL) / 20,000 units = 30 mL/hr, the correct infusion rate.
Question 3 of 5
A client is complaining of low back pain that radiates down the left posterior thigh. The nurse should ask the client if the pain is worsened or aggravated by which factor?
Correct Answer: C
Rationale: Bending or lifting can exacerbate low back pain radiating down the leg, often indicative of sciatica or a herniated disc, as these activities increase pressure on the affected nerve roots.
Question 4 of 5
The 65-year-old male client who is complaining of blurred vision reports he thinks his glasses need to be cleaned all the time, and he denies any type of eye pain. Which eye disorder should the nurse suspect the client has?
Correct Answer: D
Rationale: Blurred vision and a sensation of dirty glasses without pain are classic cataract symptoms, common in older adults due to lens clouding.
Question 5 of 5
Which intervention should the nurse include when conducting an in-service on caring for elderly clients addressing normal developmental sensory changes?
Correct Answer: A
Rationale: Open curtains increase light, aiding vision in elderly clients with age-related visual decline, such as presbyopia or cataracts.