ATI RN
NCLEX Practice Questions Skin Integrity and Wound Care Questions
Question 1 of 5
Which finding from analysis of fluid from a patient’s right knee arthrocentesis will be of concern to the nurse?
Correct Answer: A
Rationale: The correct answer is A: Cloudy fluid. Cloudy fluid from knee arthrocentesis indicates the presence of infection or inflammation, which can be concerning for the nurse. This finding suggests the presence of pus, white blood cells, or microorganisms in the fluid, indicating a possible septic joint. Scant thin fluid (B) is not concerning as it may indicate a non-inflammatory condition. Pale yellow (C) and straw-colored (D) fluids are normal findings in arthrocentesis and do not raise concerns for infection or inflammation.
Question 2 of 5
The nurse’s discharge teaching for a patient who has had a repair of a fractured mandible will include information about
Correct Answer: B
Rationale: The correct answer is B: how and when to cut the immobilizing wires. This is crucial information for the patient post-repair of a fractured mandible to ensure safe removal of the immobilizing wires as per the surgeon's instructions. Cutting them incorrectly can lead to complications or injury. A: Administration of nasogastric tube feedings is not directly related to the patient's mandible fracture repair. C: While high-fiber foods may be important for overall health, it is not specifically related to the immediate postoperative care of a fractured mandible. D: The use of sterile technique for dressing changes is important for wound care but is not directly related to the immobilizing wires for a fractured mandible.
Question 3 of 5
A patient is being discharged 4 days after hip arthroplasty using the posterior approach. Which patient action requires intervention by the nurse?
Correct Answer: B
Rationale: The correct answer is B because leaning over to pull on shoes and socks can put excessive strain on the hip joint, potentially leading to dislocation or injury post-hip arthroplasty. This action should be avoided to prevent complications. The other choices (A, C, D) are safe post-hip arthroplasty actions that promote proper weight-bearing, mobility, and independence without risking injury or dislocation.
Question 4 of 5
The second day after admission with a fractured pelvis, a patient suddenly develops confusion. Which action should the nurse take first?
Correct Answer: A
Rationale: The correct action is to take the blood pressure first because sudden confusion in a patient with a fractured pelvis could indicate a potential medical emergency like hypotension or hemorrhage. Assessing blood pressure is crucial to rule out these life-threatening conditions promptly. Checking O2 saturation, observing for facial asymmetry, and assessing patient orientation are important assessments but not the priority in this situation. O2 saturation is important for assessing respiratory status, facial asymmetry for neurological issues, and patient orientation for cognitive function, but these can be done after ruling out immediate life-threatening conditions like hypotension.
Question 5 of 5
After change-of-shift report, which patient should the nurse assess first?
Correct Answer: D
Rationale: The correct answer is D. The nurse should assess the patient with a repaired right femoral shaft fracture complaining of tightness in the calf first. This could indicate a potential complication like deep vein thrombosis (DVT), which is a serious condition requiring immediate attention to prevent further harm. Assessing for DVT is crucial as it can lead to pulmonary embolism if left untreated. Choice A is incorrect as facial pain in a patient with a repaired mandibular fracture, while important, does not pose an immediate life-threatening risk. Choice B is incorrect as an externally rotated leg in a patient with an unrepaired intracapsular left hip fracture may indicate a hip dislocation, but it is not as urgent as assessing for a potential DVT. Choice C is incorrect as wrist swelling and deformity in a patient with an unrepaired Colles’ fracture, while concerning, does not require immediate attention compared to the potential complication of DVT in the patient with the femoral shaft