ATI LPN
NCLEX Style Questions on Skin Integrity and Wound Care Questions
Question 1 of 5
When paramedics notice singed hairs in the nose of a burn patient, it is recommended that the patient be intubated. What is the reasoning for the immediate intubation?
Correct Answer: B
Rationale: In inhalation injury, the airway may become edematous quickly, making intubation difficult. Early intubation is recommended to protect the airway. Carbon monoxide poisoning may be present, but singed nose hairs are neither a symptom nor a reason for early intubation. Management of secretions is not an indication for intubation. Singed hairs and soot are more commonly symptoms of injury above the glottis rather than lower airway, below-the-glottis, signs and symptoms that will interfere with oxygenation and ventilation.
Question 2 of 5
A nurse is preparing to discharge a patient from the emergency department after receiving treatment for an ankle sprain. While providing discharge education, the nurse should encourage which of the following?
Correct Answer: D
Rationale: Treatment of a sprain consists of resting and elevating the affected part, applying cold, and using a compression bandage. After the acute inflammatory stage (usually 24 to 48 hours after injury), heat may be applied intermittently. Rotation exercises would likely be painful.
Question 3 of 5
A 20 year-old is brought in by ambulance to the emergency department after being involved in a motorcycle accident. The patient has an open fracture of his tibia. The wound is highly contaminated and there is extensive soft-tissue damage. How would this patient's fracture likely be graded?
Correct Answer: C
Rationale: Open fractures are graded according to the following criteria. Grade I is a clean wound less than 1 cm long. Grade II is a larger wound without extensive soft-tissue damage. Grade III is highly contaminated, has extensive soft-tissue damage, and is the most severe. There is no grade IV fracture.
Question 4 of 5
The nurse notes that a patient's fingertips are blue in color. What should this finding indicate to the nurse?
Correct Answer: D
Rationale: Cyanosis (blue discoloration) indicates poor perfusion or inadequate oxygenation of blood.
Question 5 of 5
The nurse is caring for a patient with 45% total body surface area thermal burns. Which laboratory value change would be expected?
Correct Answer: C
Rationale: Thermal burns cause cell damage, releasing potassium into the bloodstream (hyperkalemia), a common finding due to tissue destruction.