ATI LPN
Integumentary System Exam Questions Questions
Question 1 of 5
A nurse delegates hydrotherapy to an unlicensed assistive personnel (UAP). Which statement should the nurse include when delegating this activity?
Correct Answer: A
Rationale: Correct Answer: A Rationale: 1. Keeping water temperature constant is crucial to prevent burns or discomfort during hydrotherapy. 2. UAPs do not have the training to assess wound beds accurately; this falls under the nurse's scope of practice. 3. Applying a topical enzyme agent requires assessment and judgment beyond UAP's scope. 4. Using sterile saline for wound irrigation is a nursing task that should not be delegated to a UAP.
Question 2 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 3 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 4 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.
Question 5 of 5
The school nurse is discussing how to prevent tinea cruris with the football players. Which intervention should the nurse implement?
Correct Answer: D
Rationale: The correct answer is D because keeping the groin area dry helps prevent tinea cruris, a fungal infection commonly known as jock itch. Moisture in the groin area creates an ideal environment for the fungus to thrive. By drying the area thoroughly after bathing, football players can reduce the risk of developing tinea cruris. A: Instructing players to wear tight jock straps can actually increase moisture and friction, leading to a higher risk of tinea cruris. B: The color of socks does not impact the prevention of tinea cruris. C: Sharing brushes or combs does not directly relate to the prevention of tinea cruris.