ATI LPN
Fundamentals of Nursing: The Art and Science of Person-Centered Care Tenth, North American Edition
Chapter 33 Questions
Question 1 of 5
Based on the objective and subjective assessment of this patient, which priority problem should the nurse identify to guide the plan of care?
Correct Answer: A
Rationale: The assessment findings of nonhealing, necrotic wounds, osteomyelitis, and a foul-smelling sacral wound indicate that altered skin integrity is the priority problem. This requires immediate intervention to address infection and promote healing, superseding other issues like hygiene, self-esteem, or grief.
Question 2 of 5
The nurse has 10 minutes before having to leave the room and administer blood to another patient. Which intervention is the priority for Sam?
Correct Answer: D
Rationale: Hanging the prescribed antibiotic is the priority intervention given the diagnosed osteomyelitis, a serious bone infection requiring prompt treatment to prevent further complications. This takes precedence over emotional support, family updates, or wound care consultation within the 10-minute timeframe.
Question 3 of 5
What interventions are most likely to be effective in engaging Sam in their treatment and prevention plan? Select all that apply.
Correct Answer: A,B,C,D
Rationale: Engaging Sam involves active participation (
A), specialist interaction with reinforcement (
B), involving the partner for support (
C), and using a pressure-relief surface to prevent further wounds (
D). Teaching about the call bell and remote (E) is less relevant to wound care engagement.
Question 4 of 5
How will the nurse and Sam know that the treatment plan has been effective? Select all that apply.
Correct Answer: A,C,D
Rationale: Effective treatment is indicated by wound healing (
A), patient satisfaction and adherence (
C), and partner's ability to recognize infection signs (
D). Occasional fever (
B) suggests persistent infection, and walking a mile (E) is unrelated to wound healing outcomes.
Question 5 of 5
Thirty-six hours after having surgery, a patient has a slightly elevated body temperature and generalized malaise as well as pain with redness at the surgical site. Which action is most appropriate?
Correct Answer: A
Rationale: The assessment findings are normal for this stage of healing following surgery. The patient is in the inflammatory phase of the healing process, which involves a response by the immune system. This acute inflammation is characterized by pain, heat, redness, and swelling at the site of the injury (surgery, in this case). The patient also has a generalized body response, including a mildly elevated temperature, leukocytosis, and generalized malaise.