ATI RN
Skin Integrity and Wound Care Questions Questions
Question 1 of 5
The sacral area has remained red for two hours and does not blanch when tested. How will the nurse document this finding?
Correct Answer: D
Rationale: The correct answer is D: Reactive hyperemia. This term refers to the redness that persists after pressure is relieved due to increased blood flow to the area. In this case, the sacral area remaining red for two hours and not blanching indicates reactive hyperemia. A: Excessive pallor is incorrect as pallor refers to paleness, not redness. B: Unusual skin mottling is incorrect as mottling refers to irregular patches of skin discoloration, not persistent redness. C: Dependent sacral rubor is incorrect as rubor refers to redness due to increased blood flow, but it does not explain the persistence of redness and lack of blanching.
Question 2 of 5
The nurse encourages Aaron to select which breakfast items to provide a good source of protein?
Correct Answer: D
Rationale: The correct answer is D, eggs and orange juice. Eggs are an excellent source of high-quality protein. They provide essential amino acids needed for growth and repair of body tissues. Orange juice is a good source of vitamin C, which helps with the absorption of iron from eggs. Whole wheat toast with butter (A) and bagels with cream cheese (B) are higher in carbohydrates and fats, not protein. Oatmeal and a banana (C) are healthy options but do not provide as much protein as eggs.
Question 3 of 5
The nurse is caring for a client who is receiving IV antibiotics for the treatment of a Staphylococcus aureus infection. Which nursing interventions are appropriate when providing care to this client? Select the one that does not apply
Correct Answer: D
Rationale: The correct answer is D: Assess pain level. In this scenario, the client is receiving IV antibiotics for a Staphylococcus aureus infection, which is not typically associated with significant pain. The priority nursing interventions should focus on monitoring for allergic reactions due to antibiotic administration, assessing renal and liver function to ensure proper medication metabolism and excretion, and encouraging adequate fluid intake to prevent dehydration and support kidney function. Assessing pain level is not directly related to the treatment of Staphylococcus aureus infection with antibiotics and would not be a priority in this case.
Question 4 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 5 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.