ATI RN
NCLEX Skin Integrity Questions Questions
Question 1 of 5
Which information in a 67-yr-old woman’s health history will alert the nurse to the need for a more focused assessment of the musculoskeletal system?
Correct Answer: B
Rationale: The correct answer is B. A significant height loss in the patient's mother with aging suggests potential osteoporosis, a musculoskeletal issue common in older women. This would prompt a more focused assessment of the patient's musculoskeletal system to evaluate for osteoporosis risk factors, such as family history. Choices A, C, and D do not directly relate to musculoskeletal health or risk factors for musculoskeletal conditions. A past ankle sprain at age 13 is not a current issue; taking ibuprofen for headaches is more related to the neurological system, and the father's cause of death does not provide relevant information for assessing the patient's musculoskeletal health.
Question 2 of 5
A patient with a fracture of the left femoral neck has Buck’s traction in place while waiting for surgery. To assess for pressure areas on the patient’s back and sacral area and to provide skin care, the nurse should
Correct Answer: C
Rationale: The correct answer is C because using a trapeze to lift the buttocks slightly allows for pressure relief on the back and sacral area without compromising the traction. A: Loosening the traction can lead to displacement of the fracture and should be avoided. B: Placing a pillow between the legs does not directly address pressure areas on the back and sacral area. D: Turning the patient partially with assistance may not provide adequate pressure relief on the back and sacral area.
Question 3 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 4 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 5 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.