ATI LPN
Integumentary System Exam Questions Questions
Question 1 of 5
A nurse delegates care for a client who has open skin lesions. Which statement should the nurse include when delegating hygiene care to an unlicensed assistive personnel (UAP)?
Correct Answer: B
Rationale: The correct answer is B: Wear gloves when bathing the client. This is crucial to prevent the spread of infection from the open skin lesions. By wearing gloves, the UAP can protect themselves and the client from potential harm. A: Washing hands before touching the client is important for general hygiene, but gloves are specifically needed to prevent infection transmission. C: Assessing skin for breakdown is the nurse's responsibility, not the UAP's. D: Applying lotion to lesions while the skin is wet can introduce bacteria and is not within the UAP's scope of practice.
Question 2 of 5
Which activity can the nurse working in the outpatient clinic delegate to a licensed practical/vocational nurse (LPN/LVN)?
Correct Answer: A
Rationale: The correct answer is A because administering patch testing is a technical task that an LPN/LVN is qualified to perform. LPNs/LVNs are trained in basic patient care and medication administration. Patch testing involves applying allergens to a patient's skin to determine allergic reactions. This task does not require advanced assessment or critical thinking skills. Choice B involves interviewing a new patient about chronic health problems and allergies, which requires comprehensive assessment and critical thinking abilities typically performed by a registered nurse (RN). Choice C involves applying a sterile dressing after a medical procedure, which requires a higher level of assessment and critical thinking beyond the scope of an LPN/LVN. Choice D involves patient education after a medical procedure, which also requires a more advanced level of nursing assessment and critical thinking typically performed by an RN.
Question 3 of 5
The nurse assesses a patient who has just arrived in the postanesthesia recovery area (PACU) after a blepharoplasty. Which assessment data should be reported to the surgeon immediately?
Correct Answer: D
Rationale: The correct answer is D because pale and cold skin around the incision indicates poor circulation and potential compromised blood flow, which could lead to tissue damage or necrosis. This is a critical finding that requires immediate attention to prevent further complications. A: Incisional pain is expected postoperatively and can be managed with pain medication, it does not indicate an immediate need for intervention. B: Heart rate elevation can be a normal response to surgery and anesthesia, and 110 beats/minute may not be concerning depending on the patient's baseline and clinical context. C: Temporary loss of sensation or numbness around the incision site is common after blepharoplasty due to local anesthesia effects, and it usually resolves as the anesthesia wears off. It does not require immediate intervention unless it persists or worsens.
Question 4 of 5
The wound care nurse documented a client's pressure ulcers on admission as 3.3 cm × 4.0 cm stage II on the coccyx. Which information would alert the nurse that the client's pressure ulcer is getting worse?
Correct Answer: D
Rationale: The correct answer is D because a pressure ulcer worsening is indicated by progression to deeper tissue layers, such as the subcutaneous layer, and presence of drainage. This suggests tissue damage and increased risk of infection. Choice A describes an area of erythema that does not blanch, indicating possible skin damage but not necessarily worsening of the pressure ulcer. Choice B describes a blister, which can be a sign of pressure injury but does not necessarily indicate worsening. Choice C mentions intact skin and pain, which may suggest other issues but not necessarily worsening of the pressure ulcer.
Question 5 of 5
The client is admitted to the medical floor diagnosed with cellulitis of the left arm. Which assessment data would warrant immediate intervention by the nurse?
Correct Answer: D
Rationale: The correct answer is D because in cellulitis, there is a risk of swelling leading to impaired circulation, potentially causing compartment syndrome. Inability to remove the wedding ring indicates swelling, requiring prompt intervention to prevent circulation compromise. Choices A, B, and C do not directly indicate circulation compromise or immediate need for intervention in cellulitis. Bilaterally weak radial pulses may indicate other issues, ability to move fingers is a good sign, and a CRT less than 3 seconds is within normal range.