ATI LPN
Integumentary System Questions Questions
Question 1 of 5
A client is undergoing fluid replacement after being burned on 20% of her body 12 hours ago. The nursing assessment reveals a blood pressure of 90/50 mm Hg, a pulse rate of 110 beats/minute, and a urine output of 20 mL over the past hour. The nurse reports the findings to the health care provider (HCP) and anticipates which prescription?
Correct Answer: C
Rationale: The correct answer is C: Increasing the amount of intravenous (IV) lactated Ringer's solution administered per hour. This is the most appropriate action to address the client's hypovolemia due to burn injury. The client's low blood pressure, tachycardia, and decreased urine output indicate inadequate fluid resuscitation. Increasing the IV fluid rate will help improve perfusion and fluid balance. Option A (Transfusing 1 unit of packed red blood cells) is incorrect because the client's low blood pressure is likely due to hypovolemia rather than anemia. Option B (Administering a diuretic to increase urine output) is contraindicated as the client is already hypovolemic and needs fluid resuscitation. Option D (Changing the IV lactated Ringer's solution to one that contains 5% dextrose in water) is not appropriate as the primary concern is to address hypovolemia rather than providing additional
Question 2 of 5
What information is most important when discussing ways to prevent osteoporosis with pregnant teenagers?
Correct Answer: A
Rationale: The correct answer is A because calcium is crucial for bone health and development, especially during pregnancy. Pregnant teenagers need adequate calcium intake to support both their own bone health and the baby's growth. Calcium supplements help ensure they meet the recommended daily intake. Choice B is incorrect as foods low in calcium and high in phosphorus can actually contribute to bone density loss. Choice C is incorrect as osteoporosis can develop earlier in life, not just around age 50. Choice D, while important for overall health, does not specifically address the need for calcium intake to prevent osteoporosis during pregnancy.
Question 3 of 5
The client admitted with a diagnosis of a fractured hip who is in Buck's traction is complaining of severe pain. Which intervention should the nurse implement?
Correct Answer: B
Rationale: The correct answer is B: Ensure the weights of the Buck's traction are off the floor and hang freely. This intervention is essential to maintain proper traction and alignment of the fractured hip, which can help alleviate pain. When the weights are not hanging freely, the traction may not be effective, causing increased pain and potential complications. Explanation of why the other choices are incorrect: A: Adjusting the PCA machine for a lower dose may temporarily relieve pain, but it does not address the underlying issue of ineffective traction. C: Raising the head and foot of the bed may provide comfort but does not directly address the issue of inadequate traction. D: Turning the client on the affected leg can worsen the fracture and cause more pain, contrary to the goal of relieving pain in a client with a fractured hip in Buck's traction.
Question 4 of 5
Two unlicensed assistive personnel (UAP) are using the transfer board to move the client from the bed to the wheelchair. Which action should the nurse take?
Correct Answer: A
Rationale: The correct answer is A. The nurse should take no action because using a transfer board to move a client from the bed to the wheelchair is an appropriate and safe procedure when performed correctly by UAPs. Using a transfer board helps in ensuring a smooth and safe transfer without causing harm to the client. Instructing the UAPs not to use a transfer board (choice B) would be incorrect as it is a useful tool for transferring clients safely. Using a bed scale sling to move the client (choice C) is not appropriate for transferring the client from the bed to the wheelchair. Requesting the UAPs to stop and come to the nurse's station (choice D) is unnecessary and interrupts the transfer process.
Question 5 of 5
The emergency department nurse is caring for a 6-year-old child with a fractured forearm and suspects the injury is the result of abuse. Which x-ray finding would confirm the suspicions for the nurse?
Correct Answer: B
Rationale: The correct answer is B: A spiral fracture. Spiral fractures are often associated with twisting injuries, which are commonly seen in cases of child abuse. The spiral nature of the fracture indicates a rotational force applied to the bone, consistent with non-accidental trauma. A: A single transverse fracture is not specific to abuse and can occur from accidental falls. C: A greenstick fracture is an incomplete fracture commonly seen in children due to their bone structure, not necessarily indicative of abuse. D: A comminuted fracture, while severe, does not specifically point towards abuse as it can result from high-impact accidents. In summary, the presence of a spiral fracture in a young child raises suspicion of non-accidental trauma due to its characteristic mechanism of injury.