ATI RN
NCLEX Questions on Skin Integrity and Wound Care Questions
Question 1 of 5
Which information should the nurse include in the teaching plan for a patient diagnosed with basal cell carcinoma (BCC)?
Correct Answer: C
Rationale: The correct answer is C because minimizing sun exposure is crucial in preventing future basal cell carcinoma (BCC) development. Sun exposure is a major risk factor for BCC, so educating the patient on sun protection measures is essential. Choice A is incorrect as watchful waiting is not a typical treatment plan for BCC. Choice B is incorrect because BCC rarely metastasizes. Choice D is incorrect because systemic chemotherapy is not a common treatment for BCC. Overall, educating the patient on sun protection is key in managing and preventing BCC.
Question 2 of 5
The nurse assesses a patient who has just arrived in the post-anesthesia recovery area (PACU) after a blepharoplasty. Which assessment data should be reported to the surgeon immediately?
Correct Answer: C
Rationale: The correct answer is C because the inability to detect when the eyelids are touched may indicate nerve damage, which is a critical post-operative complication following a blepharoplasty. This should be reported immediately to the surgeon for prompt evaluation and intervention to prevent further complications. Choice A is incorrect because incisional pain is expected after surgery and can be managed with pain relief medications. Choice B, a heart rate of 110 beats/min, is elevated but not an immediate concern unless other symptoms are present. Choice D, pale and cold skin around the incision, may indicate poor circulation but is not as urgent as nerve damage in this context.
Question 3 of 5
Which medication information will the nurse identify as a potential risk to a patient’s musculoskeletal system?
Correct Answer: C
Rationale: The correct answer is C because oral corticosteroids, used to treat severe asthma, can lead to musculoskeletal issues like osteoporosis and muscle weakness. Corticosteroids can decrease bone density and increase the risk of fractures. A: Taking multivitamins and calcium supplements promotes bone health. B: Hormone replacement therapy does not directly impact the musculoskeletal system. D: NSAIDs are not typically associated with musculoskeletal risks unless used in high doses for prolonged periods.
Question 4 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 5 of 5
A patient has a long-arm plaster cast applied for fracture immobilization. Until the cast has completely dried, the nurse should
Correct Answer: B
Rationale: The correct answer is B: avoid handling the cast using fingertips. This is because handling the cast while it is still wet can deform or break it, leading to improper immobilization. It is crucial to allow the cast to dry completely to ensure proper support and healing of the fracture. Keeping the arm in a dependent position (choice A) is not necessary for the drying process. Placing gauze around the cast edge (choice C) may interfere with the drying process and cause uneven drying. Covering the cast with a blanket (choice D) may trap moisture and prolong the drying time, leading to potential complications.