ATI LPN
Fundamentals Wound Care and Skin Integrity Questions Questions
Question 1 of 5
A nurse assesses a wife who is caring for her husband with a Braden Scale score of 9. Which question should the nurse include in this assessment?
Correct Answer: B
Rationale: A Braden Scale score of 9 indicates high risk for skin breakdown; assessing the caregiver's coping is crucial.
Question 2 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 patients body. Which action should the nurse take first?
Correct Answer: C
Rationale: The nurse should note irregular patterns of bruising, especially in the shapes of hands or fingers, in different stages of resolution. These may be indications of other health problems or abuse, and should be further investigated. It is important that the nurse interview the patient alone because, if mistreatment is occurring, the patient may not disclose it in the presence of the person who may be the abuser. Throw rugs and shoes with slippery surfaces may contribute to falls. X-rays may be needed if the patient has fallen recently and also has complaints of pain or decreased mobility. However, the nurses first nursing action is to further assess the patient.
Question 3 of 5
Which information will the nurse include when teaching an older patient about skin care?
Correct Answer: C
Rationale: Warm water and moisturizing soap will avoid overdrying the skin. Because older patients have dryer skin, daily bathing and shampooing are not necessary and may dry the skin unnecessarily. Antibacterial soaps are not necessary. Lotions should be applied while the skin is still damp to seal moisture in.
Question 4 of 5
The nurse is caring for a client with deep partial-thickness and full-thickness burns to the chest area. Which assessment data would warrant notifying the health-care provider?
Correct Answer: D
Rationale: Low urinary output (50 mL in 2 hours) suggests inadequate fluid resuscitation or renal compromise, requiring immediate provider notification.
Question 5 of 5
The nurse and an unlicensed assistive personnel (UAP) are caring for clients in a dermatology clinic. Which task should not be delegated to the UAP?
Correct Answer: C
Rationale: Discussing client problems requires nursing judgment, beyond the UAP's scope.