ATI RN
NCLEX Practice Questions Skin Integrity and Wound Care Questions
Question 1 of 5
Which nursing intervention will be included in the plan of care after a patient with a right femur fracture has a hip spica cast applied?
Correct Answer: B
Rationale: The correct answer is B: Ask the patient about abdominal discomfort. This is important because the patient with a hip spica cast may experience pressure on the abdomen, leading to potential abdominal discomfort or complications. It is crucial to monitor for signs of abdominal issues promptly. A: Avoid placing the patient in prone position - While this is generally a good practice to prevent pressure ulcers, it is not directly related to the specific concern of abdominal discomfort in this scenario. C: Discuss remaining on bed rest for several weeks - While bed rest may be necessary for a period, it is not directly addressing the potential issue of abdominal discomfort from the spica cast. D: Use the cast support bar to reposition the patient - While repositioning the patient is important, the primary concern in this situation is monitoring for abdominal discomfort, not repositioning the patient.
Question 2 of 5
A patient is being discharged 4 days after hip arthroplasty using the posterior approach. Which patient action requires intervention by the nurse?
Correct Answer: B
Rationale: The correct answer is B because leaning over to pull on shoes and socks can put excessive strain on the hip joint, potentially leading to dislocation or injury post-hip arthroplasty. This action should be avoided to prevent complications. The other choices (A, C, D) are safe post-hip arthroplasty actions that promote proper weight-bearing, mobility, and independence without risking injury or dislocation.
Question 3 of 5
The second day after admission with a fractured pelvis, a patient suddenly develops confusion. Which action should the nurse take first?
Correct Answer: A
Rationale: The correct action is to take the blood pressure first because sudden confusion in a patient with a fractured pelvis could indicate a potential medical emergency like hypotension or hemorrhage. Assessing blood pressure is crucial to rule out these life-threatening conditions promptly. Checking O2 saturation, observing for facial asymmetry, and assessing patient orientation are important assessments but not the priority in this situation. O2 saturation is important for assessing respiratory status, facial asymmetry for neurological issues, and patient orientation for cognitive function, but these can be done after ruling out immediate life-threatening conditions like hypotension.
Question 4 of 5
After change-of-shift report, which patient should the nurse assess first?
Correct Answer: D
Rationale: The correct answer is D. The nurse should assess the patient with a repaired right femoral shaft fracture complaining of tightness in the calf first. This could indicate a potential complication like deep vein thrombosis (DVT), which is a serious condition requiring immediate attention to prevent further harm. Assessing for DVT is crucial as it can lead to pulmonary embolism if left untreated. Choice A is incorrect as facial pain in a patient with a repaired mandibular fracture, while important, does not pose an immediate life-threatening risk. Choice B is incorrect as an externally rotated leg in a patient with an unrepaired intracapsular left hip fracture may indicate a hip dislocation, but it is not as urgent as assessing for a potential DVT. Choice C is incorrect as wrist swelling and deformity in a patient with an unrepaired Colles’ fracture, while concerning, does not require immediate attention compared to the potential complication of DVT in the patient with the femoral shaft
Question 5 of 5
A patient whose employment requires frequent lifting has a history of chronic back pain. After the nurse has taught the patient about correct body mechanics, which patient statement indicates the teaching has been effective?
Correct Answer: B
Rationale: The correct answer is B because the patient recognizing the importance of strengthening and supporting their back aligns with the goal of preventing further back pain. Strengthening exercises can help improve muscle support and reduce the risk of injury during lifting tasks. Choice A is incorrect as lifting above the waist with a straight back may still put strain on the back. Choice C is incorrect as avoiding lifting altogether is not a practical solution for someone whose job involves frequent lifting. Choice D is incorrect as sleeping with hips and knees extended may not necessarily prevent back strain during lifting activities.