ATI LPN
Lewis's Medical Surgical Nursing in Canada, 5th Edition
Chapter 25 Questions
Question 1 of 5
Which assessment information documented in a patient's chart indicates that the nurse may need to continue to monitor the skin condition of an 82-year-old patient admitted with bacterial pneumonia?
Correct Answer: D
Rationale: Because the patient will be receiving antibiotics, the nurse should monitor the patient for the presence of an allergic rash. The assessment data in the other responses would be normal for an elderly patient.
Question 2 of 5
The nurse is caring for a patient who has a circular, flat, reddened lesion about 5 cm in diameter on his ankle. Which of the following actions would the nurse implement to determine whether the lesion is related to blood vessel dilation?
Correct Answer: B
Rationale: If the lesion is caused by blood vessel dilation, blanching will occur with direct pressure. The other assessments will assess circulation to the leg, but will not be helpful in determining the etiology of the lesion.
Question 3 of 5
The nurse is caring for a patient who is dark-skinned and has been admitted to the hospital in severe respiratory distress. Which of the following actions should the nurse implement to determine whether the patient is cyanotic?
Correct Answer: C
Rationale: Cyanosis in dark-skinned individuals is more easily seen in the mucous membranes. Earlobe colour may change in light-skinned individuals, but this change in skin colour is difficult to detect on darker skin. Application of pressure to the palms of the hands and nail bed assessment would check for adequate circulation, but not for skin colour.
Question 4 of 5
A patient asks the nurse why a potassium hydroxide test needs to be done. The nurse's response is based upon the knowledge that which of the following is the purpose of this test?
Correct Answer: C
Rationale: A potassium hydroxide test is done to examine hair, nails, or scales for superficial fungal infection. Scraping exudate from a lesion for examination is used with mineral oil slides. A Tzanck test is used when fluid is obtained from vesicles for assessment.
Question 5 of 5
The nurse is caring for a patient who has several angiomas on their legs. Which of the following actions should the nurse take next?
Correct Answer: A
Rationale: Angiomas are a common occurrence as patients age, but they may occur with systemic problems such as liver disease. The patient may want to see a dermatologist to have the angiomas removed, but this is not the initial action by the nurse. The nurse may need to educate the patient about the effects of aging on the skin and about the effects of sun exposure, but the initial action should be further assessment.