ATI RN
NCLEX Skin Integrity Questions Questions
Question 1 of 5
The nurse is teaching a mother how to administer optical antibiotics to her child who has conjunctivitis. Which statement made by the mother indicates teaching has been effective?
Correct Answer: C
Rationale: The correct answer is C because washing hands before instilling the medication helps prevent the spread of infection. Dropping medication onto the eyeball (A) can be harmful. Waiting 10 seconds between drops (B) is not necessary. Rubbing the eye with a cotton ball after administering the medication (D) can introduce bacteria.
Question 2 of 5
Which instruction should the nurse provide to an adolescent client with otitis media with regard to pain?
Correct Answer: B
Rationale: The correct answer is B: Report abrupt relief of pain immediately. This instruction is important because sudden relief of pain in otitis media may indicate rupture of the eardrum, which requires immediate medical attention. Applying a cold compress (A) may provide temporary relief but does not address the underlying issue. Continuing air travel (C) can worsen otitis media due to changes in air pressure. Reporting increased pain when moving the outer ear (D) may indicate an external ear infection, not specific to otitis media.
Question 3 of 5
The nurse is caring for an older adult client who is hospitalized with a second episode of pneumonia in the past 18 months. The client has expressed frustration to the nurse and states, 'I never got sick when I was younger. Why is this happening?' Which response by the nurse is most appropriate?
Correct Answer: B
Rationale: The correct answer is B because as individuals age, there is a natural decline in the immune response known as immunosenescence. This leads to a decreased ability to fight off infections like pneumonia, making older adults more susceptible. Option A is incorrect as the immune system doesn't simply stop working with age. Option C is incorrect because aging actually leads to a decline in immune response speed and strength. Option D is incorrect as an increase in B cells would not hinder the immune response but rather indicates a potential boost in antibody production.
Question 4 of 5
A client is admitted to the intensive care unit with a systemic infection. Which manifestations will the nurse most likely assess in this client? Select all that apply.
Correct Answer: D
Rationale: The correct answer is D: Hypotension. In systemic infection, the body's response often leads to widespread inflammation and vasodilation, resulting in decreased blood pressure. This can lead to hypotension due to decreased vascular resistance. Tachycardia (A) may also be present as the body compensates for low blood pressure by increasing heart rate. Pain (B) and Edema (C) are less likely to be directly associated with systemic infection and are not typical manifestations.
Question 5 of 5
Which diagnostic test result is consistent with a diagnosis of septic shock?
Correct Answer: B
Rationale: The correct answer is B because a hematocrit that is higher than normal is consistent with septic shock due to hemoconcentration from fluid shifting out of the blood vessels. A higher hematocrit indicates dehydration and decreased blood volume, which are common in septic shock. A is incorrect because septic shock typically results in metabolic acidosis, leading to a lower blood pH. C is incorrect because septic shock can lead to respiratory alkalosis, resulting in higher PaCO2 levels. D is incorrect because septic shock often leads to hyperkalemia, causing potassium levels to be higher than normal.