ATI RN
Fundamentals of Nursing Skin Integrity Questions Questions
Question 1 of 5
One method of preventing sepsis in hospitalized clients is
Correct Answer: A
Rationale: The correct answer is A: using aseptic techniques when inserting a catheter. This is because maintaining a sterile environment during catheter insertion helps prevent introducing harmful bacteria that can lead to sepsis. Aseptic techniques reduce the risk of infection. Choices B and C are incorrect because negative airflow rooms and airborne precautions are primarily used for airborne infections, not sepsis prevention. Choice D is incorrect as teaching proper tampon use does not directly relate to preventing sepsis in hospitalized clients.
Question 2 of 5
The charge nurse for a medical-surgical unit is notified that a client with tuberculosis (TB) is being transported to the unit. Which actions for infection prevention are the most appropriate in this circumstance? Select all that apply.
Correct Answer: B
Rationale: The correct answer is B because wearing a respirator and gown when caring for a client with TB is essential to prevent the spread of the disease through respiratory droplets. This protective equipment helps to minimize the risk of healthcare workers inhaling the TB bacteria. Choice A is incorrect because stocking the client's supply cart does not directly address infection prevention for TB. Choice C is incorrect because having the client wear a mask is not as effective as the healthcare provider wearing personal protective equipment. Choice D is incorrect because hand hygiene should be performed both before and after caring for the client with TB to prevent the spread of infection.
Question 3 of 5
The nurse assesses a circular, flat, reddened lesion about 5 cm in diameter on a middle-aged patient’s ankle. How should the nurse determine if the lesion is related to intradermal bleeding?
Correct Answer: B
Rationale: The correct answer is B: Press firmly on the lesion. By pressing firmly on the lesion, the nurse can assess if the reddened area blanches (turns white) temporarily, indicating intradermal bleeding. Elevating the leg (choice A) may help with circulation but does not directly assess intradermal bleeding. Checking skin temperature (choice C) does not provide information about intradermal bleeding. Palpating pulses (choice D) assesses vascular status but does not directly assess intradermal bleeding. Pressing firmly on the lesion is the most direct way to determine if the redness is related to intradermal bleeding.
Question 4 of 5
The nurse notes darker skin pigmentation in the skinfolds of a middle-aged patient who has a body mass index of 40 kg/m2. What is the nurse’s appropriate action?
Correct Answer: D
Rationale: The correct answer is D: Ask the patient about a personal or family history of type 2 diabetes. This is important because individuals with darker skin pigmentation and obesity are at higher risk for developing type 2 diabetes. By inquiring about the patient's personal or family history of type 2 diabetes, the nurse can gather important information to assess the patient's risk factors and potentially intervene early. Summary of other choices: A: Discussing the use of drying agents to minimize infection risk may not address the underlying health concern related to darker skin pigmentation and obesity. B: Instructing the patient about the use of mild soap to clean skinfolds is important for hygiene but does not address the potential risk of type 2 diabetes. C: Teaching the patient about treating fungal infections in the skinfolds may be relevant if there is a current infection but does not address the broader health implications of darker skin pigmentation and obesity.
Question 5 of 5
The health care provider prescribes topical 5-FU for a patient with actinic keratosis on the left cheek. The nurse should include which statement in the patient’s instructions?
Correct Answer: B
Rationale: The correct answer is B: Your cheek area will be eroded and it will take several weeks to heal. Rationale: 1. 5-FU is a topical chemotherapy agent used to treat actinic keratosis by causing erosion of the affected skin area. 2. Erosion of the skin is an expected side effect of 5-FU treatment and indicates that the medication is working to treat the actinic keratosis. 3. Healing after the erosion process can take several weeks as the skin regenerates. 4. This statement provides accurate information about the expected effects of 5-FU treatment on the patient's cheek area. Summary: - Option A is incorrect as 5-FU is not used to shrink the lesion for surgical excision but to treat actinic keratosis topically. - Option C is incorrect as nausea and anorexia are not common side effects of topical 5-FU treatment for actinic keratosis. - Option D is incorrect as