ATI RN
NCLEX Skin Integrity Questions Questions
Question 1 of 5
Which finding for a 77-yr-old patient seen in the outpatient clinic requires further nursing assessment and intervention?
Correct Answer: D
Rationale: The correct answer is D because a history of recent loss of balance and fall in an elderly patient may indicate potential underlying issues such as vestibular dysfunction, neurological problems, medication side effects, or musculoskeletal issues. Further assessment and intervention are crucial to prevent future falls and ensure patient safety. A: Symmetric joint swelling of fingers is common in older adults and may be related to arthritis or other degenerative conditions, but it does not necessarily require immediate intervention. B: Decreased right knee range of motion could be due to age-related changes or arthritis, which may warrant assessment but does not pose an immediate safety risk. C: Report of left hip aching when jogging may indicate musculoskeletal issues or overuse injury, but it does not pose an immediate safety concern that requires urgent intervention.
Question 2 of 5
A patient who has had open reduction and internal fixation (ORIF) of a hip fracture tells the nurse he is ready to get out of bed for the first time. Which action should the nurse take?
Correct Answer: A
Rationale: The correct answer is A: Check the patient’s prescribed weight-bearing status. After ORIF of a hip fracture, weight-bearing status is crucial to prevent complications. Checking this ensures the patient follows the appropriate weight-bearing restrictions. B: Using a mechanical lift is not necessary unless the patient is non-weight bearing. C: Delegating to NAP may not ensure proper assessment of weight-bearing status. D: Decreasing pain medication before getting up may lead to increased pain and reluctance to move.
Question 3 of 5
A patient who slipped and fell in the shower at home has a proximal left humerus fracture immobilized with a long-arm cast and a sling. Which nursing intervention will be included in the plan of care?
Correct Answer: C
Rationale: The correct answer is C: Assess the left axilla and change absorbent dressings as needed. This is important to monitor for skin breakdown and infection due to the immobilization of the left arm. The axilla is a common site for pressure sores in patients with arm casts. Using surgical net dressing to hang the arm from an IV pole (A) is not appropriate as it can cause discomfort and compromise circulation. Immobilizing the fingers of the left hand with gauze dressings (B) is unnecessary and can lead to stiffness and decreased circulation. Assisting the patient in passive ROM for the right arm (D) is not directly related to the care of the left humerus fracture.
Question 4 of 5
The day after a 60-yr-old patient has open reduction and internal fixation (ORIF) for an open, displaced tibial fracture, the nurse identifies the priority nursing diagnosis as
Correct Answer: D
Rationale: Rationale for Correct Answer (D): The priority nursing diagnosis is "risk for infection related to disruption of skin integrity" because the patient underwent ORIF for an open tibial fracture, which increases the risk of infection due to the disruption of skin integrity. Post-surgery, there is a higher susceptibility to infection, which can lead to serious complications and delayed healing. Monitoring for signs of infection and implementing appropriate interventions is crucial to prevent further complications. Summary of Incorrect Choices: A: Activity intolerance is not the priority as the patient is not likely to be ambulating immediately after ORIF for a tibial fracture. B: Risk for constipation is not the priority as it is not directly related to the surgical procedure and can be managed with appropriate interventions. C: Risk for impaired skin integrity is not the priority as the main concern post-ORIF is infection due to the open fracture, which takes precedence.
Question 5 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.