ATI RN
Skin Integrity and Wound Care NCLEX Questions Questions
Question 1 of 5
Which statement by a patient who has had an above-the-knee amputation indicates the nurse’s discharge teaching has been effective?
Correct Answer: B
Rationale: The correct answer is B because lying flat on the abdomen helps prevent hip flexion contractures after an above-the-knee amputation. This position stretches the hip flexors and prevents shortening of these muscles, maintaining flexibility. It also facilitates proper alignment of the residual limb, reducing the risk of contractures. Choices A, C, and D are incorrect. A: Elevating the residual limb on a pillow is not the most effective way to prevent contractures. C: Changing the limb sock is important for hygiene but not directly related to preventing contractures. D: Using lotion on the stump is beneficial for skin care but does not address the prevention of contractures.
Question 2 of 5
Before assisting a patient with ambulation 2 days after total hip arthroplasty, which action is most important for the nurse to take?
Correct Answer: B
Rationale: The correct answer is B, administer prescribed pain medication, as it ensures the patient's comfort and enables safe ambulation post-total hip arthroplasty. Pain management is crucial for successful ambulation and overall recovery. Observing output from the surgical drain (A) is important but not the priority at this time. Instructing the patient about the benefits of early ambulation (C) is essential but should come after pain management. Changing the dressing and documenting the wound appearance (D) is necessary but can be done after addressing the patient's pain.
Question 3 of 5
A patient with acute osteomyelitis of the left femur is hospitalized for regional antibiotic irrigation. Which intervention will the nurse include in the initial plan of care?
Correct Answer: B
Rationale: The correct answer is B: Immobilization of the left leg. In acute osteomyelitis, immobilization of the affected limb helps reduce movement and prevent further damage or spread of infection. Immobilization also promotes healing and allows for effective administration of regional antibiotic irrigation. Quadriceps-setting exercises (choice A) may be considered later in the treatment plan to prevent muscle atrophy but are not appropriate initially. Positioning the left leg in flexion (choice C) can worsen the infection by limiting circulation and exacerbating pain. Assisted weight-bearing ambulation (choice D) can increase pressure on the affected bone and hinder healing.
Question 4 of 5
An assessment finding for a 55-yr-old patient that alerts the nurse to the presence of osteoporosis is
Correct Answer: B
Rationale: The correct answer is B: a loss of height. Osteoporosis is characterized by decreased bone density, leading to a loss of height due to compression fractures in the spine. Bowed legs (choice A) are not typically associated with osteoporosis. The report of frequent falls (choice C) may indicate balance issues but is not specific to osteoporosis. An aversion to dairy products (choice D) may lead to a lack of calcium intake, but it is not a direct assessment finding for osteoporosis. Therefore, the presence of a loss of height is the most indicative assessment finding for osteoporosis in a 55-year-old patient.
Question 5 of 5
Which action will the nurse take when caring for a patient with osteomalacia?
Correct Answer: A
Rationale: The correct answer is A: Teach about the use of vitamin D supplements. Osteomalacia is a condition characterized by a deficiency of vitamin D, leading to weak and soft bones. Vitamin D supplements help in improving calcium absorption and bone mineralization. By educating the patient about the importance of vitamin D supplements, the nurse addresses the root cause of osteomalacia. Choice B is incorrect because while weight-bearing exercise is beneficial for bone health, it does not directly address the vitamin D deficiency seen in osteomalacia. Choice C is incorrect as bisphosphonates are typically used in conditions like osteoporosis, not osteomalacia. Choice D is incorrect as sunscreen use, although important for skin health, does not address the underlying vitamin D deficiency in osteomalacia.