ATI RN
NCLEX Questions Skin Integrity and Wound Care Questions
Question 1 of 5
Which information will the nurse include when teaching an older patient about skin care?
Correct Answer: C
Rationale: The correct answer is C: Use warm water and a moisturizing soap when bathing. This is because warm water helps maintain skin hydration and a moisturizing soap prevents dryness, which is crucial for older adults with naturally drier skin. Washing with soap daily (option B) can strip the skin of its natural oils, leading to further dryness. Option A is incorrect because drying the skin thoroughly can exacerbate dryness. Option D is incorrect as antibacterial soaps can be harsh and drying, and unnecessary for routine skin care.
Question 2 of 5
The nurse finds that a patient can flex the arms when no resistance is applied but is unable to flex when the nurse applies light resistance. The nurse should document the patient’s muscle strength as level
Correct Answer: C
Rationale: The correct answer is C (2). This patient demonstrates muscle strength that is graded as 2 according to the Medical Research Council (MRC) scale. A score of 2 indicates that the patient can move the joint against gravity but not against resistance. Choices A, B, and D are incorrect because they represent different levels of muscle strength based on the MRC scale. Choice A (0) indicates no muscle contraction, choice B (1) indicates a flicker or trace of contraction, and choice D (3) indicates movement against gravity but not against resistance. Therefore, the best description of the patient's muscle strength in this scenario is level 2.
Question 3 of 5
Which information will the nurse teach seniors at a community recreation center about ways to prevent fractures?
Correct Answer: C
Rationale: The correct answer is C: Buy shoes that provide good support and are comfortable to wear. This is crucial in preventing falls and fractures as proper footwear can improve balance and reduce the risk of slipping. Seniors should choose shoes with non-slip soles, good arch support, and a comfortable fit to prevent falls. Tacking down scatter rugs (A) can also help prevent falls, but focusing on footwear is more directly related to fracture prevention. Expecting most falls to happen outside the home (B) is not a proactive prevention strategy. Getting instruction in range-of-motion exercises (D) is important for overall mobility but does not directly address fracture prevention.
Question 4 of 5
Which statement by the patient indicates a good understanding of the nurse’s teaching about a new short-arm synthetic cast?
Correct Answer: C
Rationale: The correct answer is C because applying an ice pack to the cast over the fracture site helps reduce swelling and pain, promoting healing. This technique is commonly recommended for managing acute injuries. It shows the patient understands the importance of managing swelling in the initial phase of injury recovery. A is incorrect because getting the cast wet can weaken it and lead to skin irritation. B is incorrect as moving fingers and elbow can disrupt the healing process and cause complications. D is incorrect because applying lotion under the cast can create moisture buildup, leading to skin issues and discomfort.
Question 5 of 5
The day after a having a right below-the-knee amputation, a patient complains of pain in the missing right foot. Which action is most important for the nurse to take?
Correct Answer: B
Rationale: The correct answer is B because administering prescribed analgesics is the most important action to address the patient's pain. The pain experienced is known as phantom limb pain, which is common after amputations. Analgesics can help manage the pain effectively. Choice A is not as crucial as providing immediate pain relief. Choice C focuses on alignment rather than pain management. Choice D, while providing reassurance, does not address the immediate need for pain relief.