ATI LPN
Integumentary System Questions Questions
Question 1 of 5
A nurse is caring for a client who has a pressure ulcer on the right ankle. Which action should the nurse take first?
Correct Answer: D
Rationale: The correct action is to assess the right leg for pulses, skin color, and temperature first. This is essential to determine the perfusion and circulation to the affected area. Assessing for pulses helps in evaluating blood flow, skin color indicates tissue perfusion, and temperature can indicate infection or compromised blood flow. This assessment is crucial in identifying any circulation issues that may exacerbate the pressure ulcer. Drawing blood for lab tests (Choice A) is important but not the priority. Obtaining a wound culture (Choice B) and elevating the foot (Choice C) are important interventions but should come after assessing circulation to address the underlying cause of the pressure ulcer.
Question 2 of 5
A nurse uses the rule of nines to assess a client with burn injuries to the entire back region and left arm. How should the nurse document the percentage of the client's body that sustained burns?
Correct Answer: C
Rationale: The rule of nines divides the body into regions each representing 9% or multiples of 9% for adults. The back region is approximately 18% and the left arm is 9%. So, the total percentage of the body with burns is 18% + 9% = 27% (Choice C). The other choices are incorrect as they do not accurately represent the percentage of body surface area affected by burns based on the rule of nines.
Question 3 of 5
Which abnormality on the skin of an older patient is the priority to discuss immediately with the health care provider?
Correct Answer: D
Rationale: The correct answer is D because petechiae are tiny, pinpoint red or purple spots on the skin caused by bleeding under the skin. This could indicate a serious underlying medical condition such as a bleeding disorder or infection. It is crucial to discuss this immediately with the health care provider to determine the cause and initiate appropriate treatment. Choices A, B, and C are not as urgent as petechiae as they are more commonly seen in older adults and are not typically indicative of a serious medical issue requiring immediate attention.
Question 4 of 5
The nurse instructs a patient about application of corticosteroid cream to an area of contact dermatitis on the right leg. Which patient action indicates that further teaching is needed?
Correct Answer: C
Rationale: The correct answer is C because applying a thick layer of corticosteroid cream can lead to overuse and potential side effects such as skin thinning. The optimal amount of cream should be applied thinly to the affected area. Choice A is correct as tepid baths can help soothe the skin before application. Choice B is correct as spreading the cream in a downward motion aligns with the direction of hair growth. Choice D is incorrect as covering the area with a dressing can enhance the absorption of the cream and improve its effectiveness.
Question 5 of 5
What is the scientific rationale for placing lift pads under an immobile client?
Correct Answer: D
Rationale: The correct answer is D because lift pads help prevent friction shearing when repositioning an immobile client. Friction shearing occurs when two surfaces rub against each other, causing damage to the skin and underlying tissues. Lift pads provide a smooth surface that reduces friction, minimizing the risk of skin breakdown and pressure ulcers. Choice A is incorrect because lift pads are not designed to absorb bodily fluids. Choice B is incorrect because lift pads do not prevent diaphoresis (excessive sweating). Choice C is incorrect because the primary purpose of lift pads is not to prevent workplace injuries for staff, although they may contribute to reducing the risk of musculoskeletal injuries.