ATI LPN
Test Bank for Medical Surgical Nursing: Concepts for Interprofessional Collaborative Care 10th Edition
Chapter 24 Questions
Question 1 of 5
While assessing a client, a nurse detects a bluish tinge to the clients palms, soles, and mucous membranes. Which action should the nurse take next?
Correct Answer: B
Rationale: Cyanosis can be present when impaired gas exchange occurs. In a client with dark skin, cyanosis can be seen because the palms, soles, and mucous membranes have a bluish tinge. The nurse should assess for systemic oxygenation before continuing with other assessments.
Question 2 of 5
A nurse assesses a client who is admitted with inflamed soft-tissue folds around the nail plates. Which question should the nurse ask to elicit information about this possible condition?
Correct Answer: A
Rationale: The condition chronic paronychia is common in people with frequent intermittent exposure to water, such as homemakers, bartenders, and laundry workers. The other questions would not provide information specifically related to the assessment finding.
Question 3 of 5
A nurse assesses a client who has multiple areas of ecchymosis on both arms. Which question should the nurse ask first?
Correct Answer: D
Rationale: Certain drugs such as aspirin, warfarin, and corticosteroids can lead to easy or excessive bruising, which can result in ecchymosis. The other options would not provide information about bruising.
Question 4 of 5
After teaching a client who expressed concern about a rash located beneath her breast, a nurse assesses the clients understanding. Which statement indicates the client has a good understanding of this condition?
Correct Answer: C
Rationale: Rashes limited to skinfold areas (e.g., on the axillae, beneath the breasts, in the groin) may reflect problems related to excessive moisture. Using powder to keep the area dry is an appropriate measure to manage this condition.
Question 5 of 5
A nurse assesses a client who has two skin lesions on his chest. Each lesion is the size of a dime and has irregular borders. How should the nurse document this finding?
Correct Answer: B
Rationale: Diffuse is used to describe lesions that are widespread. The description of two lesions with irregular borders does not fit annular (circular), clustered (grouped together), or linear (in a straight line).