ATI LPN
Skin Integrity Nursing Questions Questions
Question 1 of 5
An African American is admitted to the medical unit with liver disease. To correctly assess this patient for jaundice, on what body area should the nurse look for yellow discoloration?
Correct Answer: D
Rationale: Jaundice, a yellowing of the skin, is directly related to elevations in serum bilirubin and is often first observed in the sclerae and mucous membranes.
Question 2 of 5
A patient with a 60% burn in the acute phase of treatment develops a tense abdomen, decreasing urine output, hypercapnia, and hypoxemia. Based on this assessment, the nurse anticipates interventions to evaluate and treat the patient for:
Correct Answer: C
Rationale: Intraabdominal hypertension(IAH) is a serious complication caused by circumferential torso burn injuries or edema from aggressive fluid resuscitation. Signs and symptoms of IAH include tense abdomen, decreased urine output, and worsening pulmonary function. Acute kidney injury will not result from aggressive fluid resuscitation. Acute respiratory distress syndrome would present with signs of hypoxia and hypercarbia, but not a tense abdomen. Disseminated intravascular disorder may present as a tense abdomen if there is active bleeding, but it would not present with pulmonary symptoms.
Question 3 of 5
The nurse is applying a medicated plastic wrap dressing to a patient's leg. What intervention should the nurse include in the plan of care to prevent development of complications?
Correct Answer: C
Rationale: Plastic wrap dressings should be used for no more than 12 hours a day. Wet dressings and ointments should be applied only to affected areas, not to healthy intact skin, because this can cause maceration of good skin.
Question 4 of 5
A nurse is writing a care plan for a patient admitted to the emergency department (ED) with an open fracture. The nurse will assign priority to what nursing diagnosis for a patient with an open fracture of the radius?
Correct Answer: A
Rationale: The patient has a significant risk for osteomyelitis and tetanus due to the fact that the fracture is open. Powerlessness and ineffective role performance are psychosocial diagnoses that may or may not apply, and which would be superseded by immediate physiologic threats such as infection. Surgical positioning injury is not plausible, since surgery is not likely indicated.
Question 5 of 5
A 25-year-old man is involved in a motorcycle accident and injures his arm. The physician diagnoses the man with an intra-articular fracture and splints the injury. The nurse implements the teaching plan developed for this patient. What sequela of intra-articular fractures should the nurse describe regarding this patient?
Correct Answer: A
Rationale: Intra-articular fractures often lead to post-traumatic arthritis. Research does not indicate a correlation between intra-articular fractures and FES, osteomyelitis, or compartment syndrome.