ATI RN
NCLEX Skin Integrity Questions Questions
Question 1 of 5
A client is admitted to the intensive care unit with a systemic infection. Which manifestations will the nurse most likely assess in this client? Select all that apply.
Correct Answer: D
Rationale: The correct answer is D: Hypotension. In systemic infection, the body's response often leads to widespread inflammation and vasodilation, resulting in decreased blood pressure. This can lead to hypotension due to decreased vascular resistance. Tachycardia (A) may also be present as the body compensates for low blood pressure by increasing heart rate. Pain (B) and Edema (C) are less likely to be directly associated with systemic infection and are not typical manifestations.
Question 2 of 5
The healthcare provider prescribes an indwelling urinary catheter for a client with urinary retention. Which intervention, along with strict aseptic technique, will decrease the risk of infection for this procedure?
Correct Answer: C
Rationale: Correct Answer: C - Using an anesthetic lubricating gel during insertion Rationale: Using an anesthetic lubricating gel during catheter insertion helps to reduce discomfort and trauma to the urethral mucosa, decreasing the risk of infection. This gel also helps to facilitate a smoother insertion process, reducing the chances of introducing pathogens into the urethra. Strict aseptic technique is important to prevent infection but using the lubricating gel specifically addresses the risk of trauma and discomfort during catheterization. Incorrect Choices: A: Irrigating the catheter with sterile saline on a daily basis - While irrigation with sterile saline is important for maintaining catheter patency, it does not directly decrease the risk of infection during catheter insertion. B: Instructing the client to void around the catheter - This does not address the risk of infection during catheter insertion; it is important for proper catheter care post-insertion. D: Inflating the balloon while the catheter is in
Question 3 of 5
A nurse is caring for a client with tuberculosis (TB) who is taking rifampin for treatment of the disease. Which nursing interventions are appropriate for this client? Select all that apply.
Correct Answer: C
Rationale: The correct answer is C: Administer the medication on an empty stomach. Rifampin should be administered on an empty stomach to enhance absorption. Taking it with meals reduces absorption. A: Administering with meals is incorrect as it reduces absorption. B: Recording a baseline visual examination is not specific to rifampin therapy. D: Administering by deep intramuscular injection is unnecessary and not recommended for rifampin administration. In summary, the correct answer is C because it optimizes medication absorption.
Question 4 of 5
When examining an older patient in the home, the home health nurse notices irregular patterns of bruising at different stages of healing on the patient’s body. Which action should the nurse take first?
Correct Answer: C
Rationale: Step 1: Talking with the patient alone allows for open communication and assessment of the situation. Step 2: Asking about the bruising can provide insight into the cause, such as potential abuse or neglect. Step 3: It is essential to gather information directly from the patient to ensure their safety and well-being. Step 4: This action prioritizes the patient's autonomy and right to disclose information. It also demonstrates a patient-centered approach. Summary: Option C is correct because it focuses on communication and assessment to address potential safety concerns. Options A and B address fall prevention, which is not the immediate concern. Option D jumps to radiographs without understanding the situation.
Question 5 of 5
Which information should the nurse include when teaching patients about decreasing the risk for sun damage to the skin?
Correct Answer: B
Rationale: The correct answer is B: Try to stay out of the direct sun between the hours of 10 AM and 2 PM. This is correct because UV radiation is strongest during these hours, so avoiding direct sun exposure at this time can significantly reduce the risk of sun damage. Choice A is incorrect because an SPF of at least 30 is recommended for adequate protection. Choice C is incorrect because water-resistant sunscreens may provide some protection but should be reapplied after swimming. Choice D is incorrect as increasing sun exposure can lead to skin damage rather than decrease the risk.