ATI LPN
Questions on the Integumentary System Questions
Question 1 of 5
A nurse assesses a client admitted with deep partial-thickness and full-thickness burns on the face, arms, and chest. Which assessment finding should alert the nurse to a potential complication?
Correct Answer: B
Rationale: The correct answer is B: Urine output of 20 mL/hr. This finding indicates inadequate renal perfusion, potentially leading to acute kidney injury, a common complication in burn patients. Low urine output can result from decreased cardiac output and hypovolemia due to fluid loss from burns. In contrast, choices A, C, and D are not directly related to potential complications in burn patients. Choice A (PaO₂ of 80 mm Hg) is within the normal range and does not specifically indicate a complication. Choice C (productive cough with white pulmonary secretions) could suggest a respiratory infection but is not a common complication in burn patients. Choice D (core temperature of 100.6°F) is slightly elevated but not a significant concern compared to the potential impact of inadequate renal perfusion.
Question 2 of 5
The nurse is caring for a patient diagnosed with furunculosis. Which nursing action could the nurse delegate to unlicensed assistive personnel (UAP)?
Correct Answer: D
Rationale: The correct answer is D: Cleaning the skin with antimicrobial soap. This task can be safely delegated to UAP as it does not involve any invasive or complex procedures. It is within the scope of practice for UAP and is an important aspect of managing furunculosis to prevent infection spread. Applying antibiotic cream (choice A) involves assessing the skin and determining the appropriate treatment, which requires nursing judgment. Obtaining cultures (choice B) requires specific training and knowledge to collect samples correctly. Evaluating personal hygiene (choice C) involves assessing and analyzing the patient's hygiene practices, which requires nursing assessment skills. Cleaning the skin with antimicrobial soap is a straightforward task that UAP can perform under the supervision of a nurse.
Question 3 of 5
The paraplegic client is being admitted to a medical unit from home with a stage IV pressure ulcer over the right ischium. Which assessment tool should be completed on admission to the hospital?
Correct Answer: A
Rationale: The correct answer is A: Complete the Braden Scale. This tool assesses the risk of pressure ulcers by evaluating factors such as sensory perception, moisture, activity, mobility, nutrition, and friction/shear. It is crucial to complete this assessment on admission to determine the client's risk level and develop appropriate prevention strategies. B: Monitoring the client on a Glasgow Coma Scale is not relevant in this scenario as it assesses the level of consciousness, not pressure ulcer risk. C: Assessing for Babinski's sign is a neurological assessment and not related to pressure ulcer risk assessment. D: Initiating a Brudzinski flow sheet is not a recognized tool for pressure ulcer risk assessment and is not relevant in this context.
Question 4 of 5
The school nurse is discussing impetigo with the teachers in an elementary school. One of the teachers asks the nurse, 'How can I prevent getting impetigo?' Which statement would be the most appropriate response?
Correct Answer: B
Rationale: Correct Answer: B: Do not touch any affected areas without gloves. Rationale: 1. Impetigo is a highly contagious skin infection caused by bacteria. 2. Touching affected areas without gloves can lead to the spread of bacteria. 3. Using gloves creates a barrier, reducing the risk of transmission. 4. Handwashing (Choice A) is essential but not specific to preventing impetigo. 5. Applying antibiotic to hands (Choice C) is unnecessary and ineffective. 6. Keeping the child isolated (Choice D) addresses containment, not personal prevention.
Question 5 of 5
The school nurse is assessing a teacher who has pediculosis. Which statement by the teacher makes the nurse suspect that the teacher did not comply with the instructions that were discussed in the classroom with the children?
Correct Answer: D
Rationale: Correct Answer: D Rationale: 1. The teacher mentions fixing her daughter's hair with her brush, which suggests direct contact with her daughter's hair, potentially spreading the infestation. 2. Pediculosis is transmitted through close contact, so using the same brush on an infested person can lead to reinfestation. 3. This action goes against the instructions discussed in the classroom to prevent the spread of pediculosis. 4. Choices A, B, and C do not involve direct contact with potentially infested individuals, making them less likely to contribute to the spread of pediculosis.