ATI RN
Skin Integrity and Wound Care NCLEX Questions Quizlet Questions
Question 1 of 5
Which nursing action is correct when performing the straight-leg raising test for an ambulatory patient with back pain?
Correct Answer: A
Rationale: The correct answer is A: Lift the patient's leg to a 60-degree angle from the bed. This is because the straight-leg raising test is used to assess for sciatic nerve irritation. Lifting the leg to a 60-degree angle from the bed helps to stretch the sciatic nerve and can elicit pain if there is nerve compression. Placing the patient in the prone position (B) or asking the patient to dangle both legs (C) would not provide the proper positioning for this test. Instructing the patient to elevate the legs and tense the abdominal muscles (D) is not the correct technique for performing the straight-leg raising test.
Question 2 of 5
A patient who has had open reduction and internal fixation (ORIF) of left lower leg fractures continues to complain of severe pain in the leg 15 minutes after receiving the prescribed IV morphine. Pulses are faintly palpable and the foot is cool to the touch. Which action should the nurse take next?
Correct Answer: A
Rationale: The correct answer is A: Notify the health care provider. In this scenario, the patient's severe pain, faint pulses, and cool foot suggest a potential complication such as compartment syndrome, which is a medical emergency. Notifying the health care provider immediately is crucial for prompt evaluation and intervention to prevent further complications. Repositioning the leg on pillows (choice C) may worsen the condition, assessing the incision for redness (choice B) is not the priority in this situation, and checking the patient's blood pressure (choice D) does not directly address the urgent issue at hand.
Question 3 of 5
The nurse is caring for a patient who is to be discharged from the hospital 4 days after insertion of a femoral head prosthesis using a posterior approach. Which statement by the patient indicates a need for additional instruction?
Correct Answer: D
Rationale: The correct answer is D because sleeping in any position that is comfortable for the patient after femoral head prosthesis insertion can increase the risk of dislocation. The posterior approach is more prone to dislocation with certain movements. A: Not crossing legs prevents hip dislocation. B: Using a toilet elevator reduces hip flexion. C: Having someone else put on shoes and socks prevents bending at the hip. Therefore, D is the only choice that could lead to complications.
Question 4 of 5
Which nursing action for a patient who has had right hip arthroplasty can the nurse delegate to experienced unlicensed assistive personnel (UAP)?
Correct Answer: A
Rationale: The correct answer is A: Reposition the patient every 1 to 2 hours. This task can be safely delegated to experienced UAP as it involves a routine activity to prevent pressure ulcers and maintain circulation. UAPs are trained and competent in repositioning techniques. Repositioning is crucial after hip arthroplasty to prevent complications like pressure ulcers and deep vein thrombosis. Other Choices: B: Assess for skin irritation on the patient’s back - This requires nursing assessment and critical thinking skills. UAPs are not qualified to assess for skin issues. C: Teach the patient quadriceps-setting exercises - This involves patient education and requires nursing knowledge. UAPs should not provide patient education. D: Determine the patient’s pain intensity and tolerance - Pain assessment is a nursing responsibility that requires clinical judgment and expertise. UAPs should not assess or determine pain levels.
Question 5 of 5
When assessing for Tinel’s sign in a patient with possible right carpal tunnel syndrome, the nurse will ask the patient about
Correct Answer: D
Rationale: The correct answer is D because Tinel's sign in carpal tunnel syndrome manifests as tingling in the thumb and index finger due to compression of the median nerve. This occurs when tapping over the carpal tunnel elicits tingling or pins and needles sensation. Weakness in the right little finger (A), burning in the right elbow and forearm (B), and tremor when gripping with the right hand (C) are not typically associated with Tinel's sign or specific to carpal tunnel syndrome.