ATI LPN
NCLEX Questions Skin Integrity and Wound Care Questions
Question 1 of 5
While assessing a newly postoperative patient with temperature 104.9°F, BP 90/60, pulse 58, respirations 30, jaw rigidity, and dark urine, the priority action is:
Correct Answer: B
Rationale: These signs hyperthermia, hypotension, bradycardia, tachypnea, jaw rigidity, dark urine suggest malignant hyperthermia (MH), an anesthesia emergency. Notifying the surgeon is urgent, per MH protocols, for dantrolene administration. Relaxation or pain meds don't treat MH. Sponge bath delays critical care. Immediate reporting triggers life-saving intervention, an LPN priority, making it the correct action.
Question 2 of 5
You are observing a nursing student perform a dressing change. You would intervene if the student:
Correct Answer: D
Rationale: Dressing changes balance sterility and practicality. Using sterile gloves to remove old dressing is incorrect clean gloves suffice, per infection control, reserving sterile for new application. Gathering supplies (Choice A), identifying patient (Choice B), and hand hygiene with clean gloves are standard. Sterile removal wastes resources and risks contamination later, needing intervention, making it the correct action.
Question 3 of 5
You administer ketorolac 30 mg IM. The gate control theory indicates the next action to assist in pain control would be to:
Correct Answer: D
Rationale: Gate control theory posits non-pain stimuli block pain signals. Encouraging distraction e.g., music enhances ketorolac's effect, per pain management. Recapping is safety, not pain-related. Massaging may worsen IM irritation. Checking later assesses, doesn't aid. Distraction leverages theory, an LPN adjunct, making it the correct next action.
Question 4 of 5
A patient with chronic pain asks, 'What is a TENS unit?' The best nursing response is:
Correct Answer: B
Rationale: TENS (transcutaneous electrical nerve stimulation) uses skin electrodes to disrupt pain signals, per gate control theory.'Small electrical stimulus' accurately describes it, per nursing texts. Epidural is invasive, not TENS. Finger pressure is acupressure. Support misleads. Clear explanation aids use, an LPN response, making it the correct answer.
Question 5 of 5
Which priority element will the nurse consider when planning care to decrease the development of a decubitus ulcer for an unconscious patient?
Correct Answer: B
Rationale: Pressure is the primary cause of decubitus ulcers, as it disrupts capillary flow when exceeding 15-32 mm Hg, leading to ischemia, per the text. For an unconscious patient, sustained pressure from immobility is the critical factor nurses address through repositioning and support surfaces. Resistance isn't a defined element here. Weight contributes indirectly via pressure distribution but isn't the root cause. Stress affects overall health, not ulcer formation directly. Pressure's intensity, duration, and tissue tolerance are measurable and actionable, making it the priority element in care planning to prevent skin breakdown in vulnerable patients.