ATI LPN
Integumentary System Questions Questions
Question 1 of 5
The long-term care nurse has received the a.m. shift report. Which client should the nurse assess first?
Correct Answer: C
Rationale: The correct answer is C because periorbital skin lesions could indicate a serious issue like an infection or skin condition that requires immediate attention to prevent complications. Assessing this client first is crucial to address potential health risks. Choice A is not the priority as not having a bowel movement today may not be an urgent concern if the client is not experiencing discomfort or other symptoms. Choice B could be important but changing an indwelling catheter can typically wait a bit longer without immediate harm. Choice D, a stage I pressure ulcer, is concerning but usually does not require immediate attention compared to a potential skin infection indicated by periorbital lesions.
Question 2 of 5
A client is undergoing fluid replacement after being burned on 20% of her body 12 hours ago. The nursing assessment reveals a blood pressure of 90/50 mm Hg, a pulse rate of 110 beats/minute, and a urine output of 20 mL over the past hour. The nurse reports the findings to the health care provider (HCP) and anticipates which prescription?
Correct Answer: C
Rationale: The correct answer is C: Increasing the amount of intravenous (IV) lactated Ringer's solution administered per hour. This is the most appropriate action to address the client's hypovolemia due to burn injury. The client's low blood pressure, tachycardia, and decreased urine output indicate inadequate fluid resuscitation. Increasing the IV fluid rate will help improve perfusion and fluid balance. Option A (Transfusing 1 unit of packed red blood cells) is incorrect because the client's low blood pressure is likely due to hypovolemia rather than anemia. Option B (Administering a diuretic to increase urine output) is contraindicated as the client is already hypovolemic and needs fluid resuscitation. Option D (Changing the IV lactated Ringer's solution to one that contains 5% dextrose in water) is not appropriate as the primary concern is to address hypovolemia rather than providing additional
Question 3 of 5
For a client diagnosed with lumbar strain, which nursing interventions should be included in the plan of care?
Correct Answer: A
Rationale: Step 1: Assessing pain on a 1-to-10 scale is crucial in managing lumbar strain as it helps determine the severity and effectiveness of interventions. Step 2: Pain assessment guides treatment adjustments and ensures optimal pain control for the client. Step 3: Administering pain medication PRN without proper assessment may lead to overmedication or under-treatment. Step 4: Providing a regular bedpan for elimination is not directly related to managing lumbar strain. Step 5: Assessing surgical dressing every four hours is not necessary for a client with lumbar strain unless there are specific indications.
Question 4 of 5
What information is most important when discussing ways to prevent osteoporosis with pregnant teenagers?
Correct Answer: A
Rationale: The correct answer is A because calcium is crucial for bone health and development, especially during pregnancy. Pregnant teenagers need adequate calcium intake to support both their own bone health and the baby's growth. Calcium supplements help ensure they meet the recommended daily intake. Choice B is incorrect as foods low in calcium and high in phosphorus can actually contribute to bone density loss. Choice C is incorrect as osteoporosis can develop earlier in life, not just around age 50. Choice D, while important for overall health, does not specifically address the need for calcium intake to prevent osteoporosis during pregnancy.
Question 5 of 5
The client admitted with a diagnosis of a fractured hip who is in Buck's traction is complaining of severe pain. Which intervention should the nurse implement?
Correct Answer: B
Rationale: The correct answer is B: Ensure the weights of the Buck's traction are off the floor and hang freely. This intervention is essential to maintain proper traction and alignment of the fractured hip, which can help alleviate pain. When the weights are not hanging freely, the traction may not be effective, causing increased pain and potential complications. Explanation of why the other choices are incorrect: A: Adjusting the PCA machine for a lower dose may temporarily relieve pain, but it does not address the underlying issue of ineffective traction. C: Raising the head and foot of the bed may provide comfort but does not directly address the issue of inadequate traction. D: Turning the client on the affected leg can worsen the fracture and cause more pain, contrary to the goal of relieving pain in a client with a fractured hip in Buck's traction.