ATI RN
Skin Integrity and Wound Care Questions Questions
Question 1 of 5
The nurse is caring for a client who is hospitalized for cellulitis of the foot. Which nursing diagnoses should the nurse use to plan this client's care? Select the one that does not apply
Correct Answer: A
Rationale: The correct answer is A: Social Isolation related to skin infection. Cellulitis primarily affects the physical aspect of the client's health, not their social interactions. The client's main concerns are related to the physical symptoms, such as impaired skin integrity, acute pain, and disturbed sleep pattern. These nursing diagnoses directly address the client's physical needs and promote healing. Social isolation is not directly related to cellulitis and would not be a priority nursing diagnosis in this case.
Question 2 of 5
The nurse is caring for a client who presents with acute malaise, muscle aches, and fever. Which additional assessment findings should the nurse recognize as consistent with influenza? Select the one that does not apply
Correct Answer: C
Rationale: The correct answer is C: Hypotension. Influenza typically presents with symptoms such as malaise, muscle aches, fever, and a nonproductive cough. Hypotension is not a common symptom of influenza. It is more indicative of other conditions like sepsis or dehydration. Difficulty urinating is not typically associated with influenza either. A lack of recent vaccinations (choice A) can contribute to susceptibility to influenza, and a nonproductive cough (choice B) is a common respiratory symptom seen in influenza cases. Thus, hypotension is the outlier among these assessment findings.
Question 3 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 4 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 5 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.