ATI RN
NCLEX Skin Integrity Questions Questions
Question 1 of 5
When a patient arrives in the emergency department with a facial fracture, which action will the nurse take first?
Correct Answer: D
Rationale: The correct answer is D: Check the patient’s alertness and orientation. This is the priority because it assesses the patient's level of consciousness and neurological status, which is crucial in determining the severity of the facial fracture and any potential associated injuries. Assessing alertness and orientation helps in identifying any signs of head trauma or neurological deficits. This initial assessment guides further interventions and ensures timely and appropriate care. Incorrect choices: A: Assess for nasal bleeding and pain - This is important but assessing the patient's alertness and orientation takes precedence. B: Apply ice to the face to reduce swelling - While this can be helpful later, it is not the first priority in a patient with a facial fracture. C: Use a cervical collar to stabilize the spine - Stabilizing the spine is important in trauma, but in this scenario, assessing the patient's alertness and orientation is more critical.
Question 2 of 5
Which assessment finding for a patient who has had surgical reduction of an open fracture of the right radius requires notification of the health care provider?
Correct Answer: D
Rationale: The correct answer is D because a temperature of 101.4°F indicates possible infection post-surgery, requiring immediate notification of the healthcare provider for further evaluation and treatment. Elevated temperature can indicate systemic infection. A: Serous wound drainage is expected post-surgery and not concerning. B: Right arm pain with movement is typical after surgical reduction and should be managed with pain medication. C: Right arm muscle spasms can be a normal response to surgery and may resolve with proper rest and care.
Question 3 of 5
A nurse is teaching a patient with contact dermatitis of the arms and legs about ways to decrease pruritus. Which information should the nurse include in the teaching plan(select the one that does not apply)?
Correct Answer: C
Rationale: The correct answer is C. Adding oil to bath water can exacerbate contact dermatitis by further irritating the skin. Oil can create a barrier that traps irritants and moisture, worsening symptoms. The other options are appropriate for managing pruritus in contact dermatitis. A: Cool, wet cloths or compresses can provide relief by soothing and reducing inflammation. B: Cool or tepid baths help to soothe the skin and reduce itching. D: Rubbing dry with a towel after bathing helps prevent skin maceration and further irritation. Adding oil to bath water is contra-indicated in contact dermatitis management.
Question 4 of 5
Atopic dermatitis can be described as: Select all that apply.
Correct Answer: B
Rationale: Atopic dermatitis is characterized by oozing due to the disrupted skin barrier. Vesicle formation is more characteristic of allergic contact dermatitis. Round, erythematous papules that enlarge and coalesce are seen in nummular eczema. Raised wheals with associated itching are typical of urticaria. Oozing is specific to atopic dermatitis due to impaired skin barrier function.
Question 5 of 5
Which of the following actions could result in pressure ulcer formation?
Correct Answer: A
Rationale: The correct answer is A because pulling a stroke client up in bed can create friction and shear forces on the skin, leading to pressure ulcer formation. This action puts pressure on vulnerable areas of the skin, especially if the client is immobile or has limited mobility. Turning a client from side to side every 2 hours (B) is actually a preventive measure to reduce pressure ulcer risk by redistributing pressure. Allowing a client to slide up in a chair at mealtime (C) may not directly contribute to pressure ulcers unless prolonged pressure is exerted. Applying powder to buttocks area when diaphoresis has become a problem (D) can help reduce moisture but is not a direct cause of pressure ulcers.