ATI RN
NCLEX Questions Skin Integrity and Wound Care Questions
Question 1 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 2 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 3 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 4 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.
Question 5 of 5
The nurse will determine more teaching is needed if a patient with discomfort from a bunion says, “I will
Correct Answer: D
Rationale: The correct answer is D because wearing only sandals and avoiding closed-toe shoes will not effectively address the discomfort from the bunion. This response indicates a lack of understanding about proper footwear choices to reduce pressure on the bunion. Other choices (A, B, C) show actions that may actually help alleviate discomfort temporarily, like giving away high-heeled shoes, using a bunion pad, or taking ibuprofen. However, these choices do not address the root cause of the issue, which is pressure and friction on the bunion. Therefore, choice D is the correct answer as it highlights the need for further education on appropriate footwear to manage bunion discomfort effectively.