ATI RN
NCLEX Questions on Skin Integrity and Wound Care Questions
Question 1 of 5
Which action can the nurse delegate to unlicensed assistive personnel (UAP) who are working in the orthopedic clinic?
Correct Answer: B
Rationale: The correct answer is B. UAP can safely obtain a blood sample for uric acid from a patient with gout as it is a non-invasive task that does not require specialized nursing knowledge. The rationale includes: 1. UAP training often includes basic phlebotomy skills. 2. Blood sample collection is a routine task that can be delegated. 3. Uric acid testing is a common diagnostic procedure for gout. Other choices require higher-level nursing assessment and intervention skills, which UAP are not trained or qualified to perform. A: Assessing muscle strength requires nursing judgment. C: Performing straight-leg-raise testing involves potential risk of injury. D: Checking for knee crepitation before surgery requires specific knowledge and expertise.
Question 2 of 5
After the health care provider recommends amputation for a patient who has nonhealing ischemic foot ulcers, the patient tells the nurse that he would rather die than have an amputation. Which response by the nurse is best?
Correct Answer: C
Rationale: The correct answer is C because it demonstrates active listening and allows the nurse to assess the patient's understanding and concerns about the treatment options. By asking the patient to share what they know, the nurse can address any misconceptions, provide additional information, and involve the patient in decision-making. Choice A is incorrect because it dismisses the patient's feelings and does not address the patient's concerns. Choice B is incorrect because it assumes the patient will be open to using a foot prosthesis without exploring the patient's preferences further. Choice D is incorrect because it does not address the patient's need for information and support in making an informed decision about their treatment options.
Question 3 of 5
After being hospitalized for 3 days with a right femur fracture, a patient suddenly develops shortness of breath and tachypnea. The patient tells the nurse, 'I feel like I am going to die!' Which action should the nurse take first?
Correct Answer: B
Rationale: The correct action for the nurse to take first is to administer prescribed PRN O2 at 4 L/min (Choice B). This is the correct choice because the patient is showing signs of respiratory distress, which could indicate a pulmonary embolism, a potentially life-threatening complication following a femur fracture. Administering oxygen can help improve oxygenation and stabilize the patient's condition. It is essential to address the immediate physiological need for oxygen before taking further action. Staying with the patient and offering reassurance (Choice A) may be important but addressing the respiratory distress is the priority. Checking the patient's legs for swelling or tenderness (Choice C) may help in assessing for a potential deep vein thrombosis, but it is not the most urgent action in this scenario. Notifying the health care provider (Choice D) can be done after stabilizing the patient's condition with oxygen.
Question 4 of 5
A patient is admitted to the emergency department with a left femur fracture. Which information obtained by the nurse is most important to report to the health care provider?
Correct Answer: C
Rationale: The correct answer is C: Slow capillary refill of the left foot. This is the most important information to report because it indicates potential compromised blood flow to the affected limb, which can lead to serious complications like ischemia and tissue damage. The priority in managing a femur fracture is to ensure adequate blood supply to prevent further damage. Choice A (Ecchymosis) is important but not as urgent as compromised circulation. Choice B (Severe pain) is expected with a femur fracture and can be managed with pain medication. Choice D (Outward pointing toes) is a concerning sign but does not directly indicate compromised circulation like slow capillary refill does.
Question 5 of 5
When caring for a patient who is using Buck’s traction after a hip fracture, which action can the nurse delegate to unlicensed assistive personnel (UAP)?
Correct Answer: B
Rationale: Correct Answer: B Rationale: 1. Ensuring the weight for traction hangs freely prevents complications and maintains proper alignment. 2. This task does not require specialized skills or judgment, making it suitable for delegation to UAP. 3. UAP can be trained to understand the importance of maintaining proper traction alignment. 4. Monitoring skin condition (C) requires assessment skills, removing/reapplying traction (A) is a specialized task, and checking sensation/movement (D) requires clinical judgment.