ATI LPN
Skin Integrity Practice Questions Questions
Question 1 of 5
An elderly individual from an assisted living facility presents with severe scald burns to the buttocks and back of the thighs. The caregiver from the ALF accompanies the patient to the emergency department and states that the bath water was too hot" and that the "patient sat in the water too long." What should the nurse do?"
Correct Answer: B
Rationale: In cases of suspected abuse, especially in vulnerable patients such as children, elderly, and mentally impaired, it is important to assess the injured patient separately from the caregiver. While obtaining safety information on the temperature of the water heater is important, it is not a priority assessment question. The nurse should follow the hospital protocol for contacting appropriate authorities concerning suspected abuse, which may include contacting the police or social services. Asking the caregiver to describe how the injury occurred is important(e.g., there may be discrepancies in the physical assessment and reported mechanism of burn injury); however, examining the patient away from the caregiver is a priority.
Question 2 of 5
A nurse is caring for a patient who has suffered a hip fracture and who will require an extended hospital stay. The nurse should ensure that the patient does which of the following in order to prevent common complications associated with a hip fracture?
Correct Answer: C
Rationale: Deep vein thrombosis (DVT) is among the most common complications related to a hip fracture. To prevent DVT, the nurse encourages intake of fluids and ankle and foot exercises. The patient should not be told to endure pain; a proactive approach to pain control should be adopted. While respiratory complications commonly include atelectasis and pneumonia, the use of deep-breathing exercises, changes in position at least every 2 hours, and the use of incentive spirometry help prevent the respiratory complications more than using supplementary oxygen. Bed rest may be indicated in the short term, but is not normally required for 14 days.
Question 3 of 5
A nurse is planning the care of a patient with osteomyelitis that resulted from a diabetic foot ulcer. The patient requires a transmetatarsal amputation. When planning the patient's postoperative care, which of the following nursing diagnoses should the nurse most likely include in the plan of care?
Correct Answer: C
Rationale: Amputations present a serious threat to any patient's body image. None of the other listed diagnoses is specifically associated with amputation.
Question 4 of 5
The nurse notes that a patient has longitudinal red lines in the finger nails. What health problem should the nurse suspect is causing this problem?
Correct Answer: C
Rationale: Longitudinal red lines in nails can indicate bacterial endocarditis due to vascular changes.
Question 5 of 5
The nurse is evaluating care provided to a patient with burns during the emergent phase. Which data indicates that additional fluid resuscitation is required?
Correct Answer: D
Rationale: A low central venous pressure (e.g., 2 mm Hg) indicates hypovolemia, suggesting inadequate fluid resuscitation in the emergent phase of burn care.