ATI LPN
Skin Integrity and Wound Care Questions Questions
Question 1 of 5
If you identify a clinical concern that has the potential to cause patient harm, what is the best way to ensure there will be appropriate evaluation of that concern?
Correct Answer: A
Rationale: Incident reporting triggers investigation. Filing a NETS report , per the test, systematically tracks and analyzes safety events per health system policy, ensuring follow-up. Supervisor contact or CEO notification may escalate but lack structure. M&M educates, not investigates. NETS enables data-driven solutions, like fixing equipment flaws, making it the correct way.
Question 2 of 5
A nurse is caring for a client with bacterial pneumonia and a temperature of 104°F (40.0°C). Yesterday, the client's temperature was 102°F (38.9°C). The health care provider on call prescribes cool compresses for the client to help lower the fever. The client insists that the nurse bring warm blankets because they will help the client to recover more quickly. The nurse recognizes that the client's request is an example of:
Correct Answer: A
Rationale: Client beliefs reflect culture. Requesting warm blankets is a ritual, per nursing texts, possibly tied to traditional healing (e.g., sweating out illness). Stereotyping is nurse assumption, not client action. Competence is nurse skill. No Choice D exists. This cultural ritual guides respectful care, making it correct.
Question 3 of 5
The nurse is preparing to provide wound care to a client with a stage 1 pressure injury. Which dressing would the nurse expect to be prescribed in the treatment of this wound?
Correct Answer: B
Rationale: Stage 1 injuries are intact. Transparent dressing , per Braden Scale care, protects non-open skin (red, no breakdown) while allowing monitoring. Hydrogel adds moisture for open wounds. Antimicrobial targets infection, unneeded here. Alginate suits heavy drainage. Transparency preserves integrity and prevents progression, making it the expected choice.
Question 4 of 5
A client is admitted with a burn injury that involves the epidermis and part of the dermis. The nurse knows that this type of burn is classified as:
Correct Answer: B
Rationale: A burn involving the epidermis and part of the dermis is classified as a partial-thickness burn, making choice B the correct answer. This type of burn typically presents with blisters, significant pain due to exposed nerve endings, and redness as blood vessels in the dermis are affected. It may heal spontaneously within two to three weeks with proper care or require skin grafting if deeper layers are involved. Superficial burns only affect the epidermis, causing mild pain and erythema without blisters, and heal quickly within days without scarring. Full-thickness burns extend through the epidermis, dermis, and into underlying tissues like fat or muscle, resulting in a charred appearance, no pain due to nerve destruction, and the need for surgical intervention. Deep partial-thickness burns involve most of the dermis, presenting with white or red skin and severe pain, often requiring grafting due to slower healing. The distinction lies in the depth of tissue involvement, and partial-thickness best matches the description provided.
Question 5 of 5
A client with a burn wound on the chest has a silver sulfadiazine (Silvadene) cream applied to the wound. Which adverse reaction should the nurse monitor for in this client?
Correct Answer: D
Rationale: as the nurse should monitor for both hypersensitivity or allergic reaction and leukopenia or decreased white blood cell count when using silver sulfadiazine (Silvadene) on a burn wound. This topical antimicrobial can cause allergic reactions like rash, itching, or swelling, which may escalate to severe symptoms like difficulty breathing, requiring immediate attention. It can also lead to leukopenia, a drop in white blood cells, increasing infection risk, necessitating regular blood count monitoring. Hyperglycemia isn't a typical adverse reaction to Silvadene; it may occur in burn patients due to stress or infection, not the cream itself. Since both A and B are valid concerns supported by the need for baseline and periodic complete blood counts choice D encompasses the full scope of critical monitoring, ensuring comprehensive care for potential complications.