ATI LPN
Integumentary System Questions Questions
Question 1 of 5
The client, age 20, dies after an unsuccessful resuscitation attempt. What nursing action is indicated first?
Correct Answer: B
Rationale: The correct answer is B: Document the time of death. This action is indicated first as it is crucial for legal and medical records. It provides an accurate timestamp for the event. Notifying the funeral home (A) is premature without proper documentation. Contacting the physician (C) may be needed later, but documenting the time of death takes precedence. Contacting the orderly for transport (D) should only occur after the time of death is documented.
Question 2 of 5
A client asks which method of contraception will provide the greatest protection against sexually transmitted infections. What method can the nurse recommend?
Correct Answer: B
Rationale: The correct answer is B: Male condoms. Condoms provide a physical barrier that can significantly reduce the risk of sexually transmitted infections (STIs) by preventing direct contact between bodily fluids. They are the most effective method for STI protection. Oral contraceptives (A) do not protect against STIs. Sponges (C) and spermicides (D) offer some pregnancy protection but do not provide significant STI protection like condoms do.
Question 3 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 4 of 5
A nurse cares for older adult clients in a long-term acute care facility. Which intervention should the nurse implement to prevent skin breakdown?
Correct Answer: A
Rationale: The correct answer is A: Use a lift sheet when moving the client in bed. This intervention is crucial for preventing skin breakdown in older adults as it reduces friction and shear forces on the skin. Moving the client without a lift sheet can cause pressure ulcers. Avoiding tape (B) is important to prevent skin irritation but not specifically for skin breakdown prevention. Whirlpool therapy (C) can be beneficial for wound healing but is not directly related to preventing skin breakdown. Using loose dressings (D) may not provide adequate protection and could lead to further complications.
Question 5 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.