ATI RN
Skin Integrity and Wound Care Questions Questions
Question 1 of 5
The nurse is assessing a college student who presents with red, swollen eyes; photophobia; and yellowish drainage from the conjunctiva. Which question should the nurse ask the client first?
Correct Answer: D
Rationale: The correct question to ask the client first is D: "Have any of your friends experienced these symptoms?" This question helps identify if the symptoms are due to a contagious condition like conjunctivitis, commonly known as pink eye. By inquiring about friends' symptoms, the nurse can assess potential exposure and recommend appropriate precautions. Explanation for other choices: A: Asking about caffeine consumption is unrelated to the client's eye symptoms. B: Inquiring about sand in the eye is not relevant to the symptoms described. C: Asking about HIV exposure is not the priority as the symptoms presented are indicative of a different condition.
Question 2 of 5
The nurse is caring for a client who refuses treatment for otitis media. The nurse correctly teaches the client that she is at increased risk for developing which condition?
Correct Answer: B
Rationale: The correct answer is B: Meningitis. Otitis media is an infection of the middle ear, and if left untreated, the infection can spread to the meninges, causing meningitis. Meningitis is a serious condition that can lead to inflammation of the brain and spinal cord. This progression from otitis media to meningitis highlights the importance of treating infections promptly to prevent complications. Choices A, C, and D are incorrect as there is no direct causal relationship between otitis media and external otitis, pneumonia, or influenza.
Question 3 of 5
An older adult client is admitted with pneumonia. Which manifestations would the nurse expect to find when assessing this client? Select all that apply.
Correct Answer: A
Rationale: The correct answer is A: Hemoptysis. In pneumonia, hemoptysis (coughing up blood-tinged sputum), is a common symptom due to inflammation and infection in the lungs. It is caused by the destruction of lung tissue and blood vessels. Increased appetite (B) is unlikely as pneumonia typically causes a decreased appetite due to feeling unwell. Cough (C) is a common manifestation of pneumonia, but it is not specific to pneumonia alone. Tachypnea (D) is also a common symptom of pneumonia due to the body's attempt to increase oxygen intake, but it is not as specific as hemoptysis in this context.
Question 4 of 5
The provider has ordered fluid administration for a pediatric client with pneumonia. The client weighs 81.6 lb (37 kg). The nurse should expect to administer ________ mL of fluid per day for this client.
Correct Answer: A
Rationale: To calculate fluid administration for a pediatric client, use the formula: 100 mL/kg for the first 10 kg, 50 mL/kg for the next 10 kg, and 20 mL/kg for each kg above 20 kg. For a 37 kg client, the calculation is: (10 kg x 100 mL) + (10 kg x 50 mL) + (7 kg x 20 mL) = 1840 mL/day (Answer A). This is the correct answer because it follows the appropriate formula based on the client's weight. Choices B, C, and D are incorrect as they do not follow the correct calculation method for fluid administration based on weight.
Question 5 of 5
List the pathophysiology concepts related to the onset of sepsis in sequential order.
Correct Answer: A
Rationale: The correct sequence for the pathophysiology of sepsis onset is as follows: 1. Macrophage-producing cytokines are released. 2. Endotoxin released by microorganisms triggers an inflammatory response. 3. Neutrophils arrive and multiply, leading to capillary occlusion. 4. Vasodilation occurs with increased capillary permeability and fluid leak. Macrophage cytokines initiate the cascade of events by signaling the immune response. Endotoxin release exacerbates inflammation. Neutrophil accumulation causes capillary blockage. Vasodilation and increased permeability follow, leading to septic shock. Other choices are incorrect as they do not follow the correct sequence of events in sepsis pathophysiology.