ATI RN
NCLEX Questions Skin Integrity and Wound Care Questions
Question 1 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 2 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.
Question 3 of 5
A patient arrived at the emergency department after tripping over a rug and falling at home. Which finding is most important for the nurse to communicate to the health care provider?
Correct Answer: C
Rationale: The correct answer is C: The right arm appears shorter than the left. This finding suggests a possible shoulder dislocation or fracture, which requires immediate medical attention to prevent further complications. Shortening of the affected limb is a classic sign of a fracture or dislocation. Communicating this to the healthcare provider promptly can expedite appropriate treatment. Incorrect choices: A: There is bruising at the shoulder area - Bruising alone may not indicate a serious injury compared to limb shortening. B: The patient reports arm and shoulder pain - Pain is a common symptom after a fall and may not indicate a specific serious injury. D: There is decreased shoulder range of motion - While decreased range of motion is concerning, limb shortening is a more critical finding indicating a structural injury.
Question 4 of 5
A patient undergoes left above-the-knee amputation with an immediate prosthetic fitting. When the patient arrives on the orthopedic unit after surgery, the nurse should
Correct Answer: A
Rationale: The correct answer is A: assess the surgical site for hemorrhage. After an above-the-knee amputation, assessing the surgical site for hemorrhage is crucial as it helps in early detection and management of any bleeding, which can be life-threatening. Other choices are incorrect: B is wrong as removing the prosthesis can disrupt wound healing; C is incorrect as it doesn't address the immediate post-op concern of hemorrhage; D is incorrect as keeping the residual limb elevated on a pillow may not be the priority over assessing for hemorrhage.
Question 5 of 5
Based on the information in the accompanying figure obtained for a patient in the emergency room, which action will the nurse take first?
Correct Answer: C
Rationale: The correct answer is C: Check the patient’s O2 saturation using pulse oximetry. This is the first action the nurse should take because it directly assesses the patient's oxygen levels, which is crucial for determining the patient's immediate respiratory status and need for intervention. Monitoring oxygen saturation helps in identifying hypoxemia, which can be life-threatening and requires prompt attention. Administering morphine IV (choice A) could potentially worsen respiratory depression if the patient is already hypoxic. Contacting the operating room for surgery (choice B) is not appropriate without assessing the patient's oxygenation first. Asking about the date of the last tetanus immunization (choice D) is important but not the priority when the patient's oxygenation is in question.