ATI RN
Fundamentals of Nursing Skin Integrity Questions Questions
Question 1 of 5
What action should the nurse take regarding the positioning schedule?
Correct Answer: A
Rationale: The correct answer is A because providing verbal instructions to the UAP ensures clear communication, which is crucial for consistent care. Documenting the instructions in the nurse's notes helps track the care provided. Choice B involves unnecessary escalation and may not be efficient. Choice C is incorrect as client confidentiality is always a priority. Choice D overlooks the importance of direct communication and documentation in ensuring proper care.
Question 2 of 5
The healthcare provider prescribes a client to have peak and trough blood levels drawn to evaluate the therapeutic effect of an IV antibiotic. When should the nurse schedule the blood samples to be drawn?Select the one that does not apply
Correct Answer: A
Rationale: The correct answer is A. Peak levels are drawn 30 minutes after the IV infusion, while trough levels are drawn just before the next dose is given, so B is incorrect. Drawing blood during the infusion, as in C, would not provide accurate peak or trough levels. Drawing blood 30 minutes after administration, as in D, is not specifically timed for peak or trough levels. Drawing blood before discontinuing the antibiotic, as in A, ensures accurate trough levels and helps assess the drug's effectiveness.
Question 3 of 5
The nurse is teaching a client with cellulitis about ways to promote healing and avoid future infections. Which client statements indicate that the teaching has been effective?Select the one that does not apply
Correct Answer: C
Rationale: Rationale: Choice C is correct because a temperature of 99.5°F or higher can indicate an infection, and prompt medical attention is crucial. Choice A is incorrect as antibiotic soap can disrupt normal skin flora. Choice B is incorrect as some moisture is needed for wound healing. Choice D is incorrect as swimming in lakes can introduce bacteria to the wound.
Question 4 of 5
When planning care for a client with trachoma, which potential complication should the nurse consider?
Correct Answer: A
Rationale: The correct answer is A: Scarring of the cornea. Trachoma is a bacterial infection that can lead to scarring of the cornea, which may result in vision impairment or blindness. The scarring occurs due to repeated episodes of inflammation and infection in the eyes. This complication is common in advanced cases of trachoma. Choice B, eye muscle weakness, is not a typical complication of trachoma but rather can be associated with other eye conditions. Choice C, damaged iris, is not a common complication of trachoma as the infection primarily affects the surface of the eye. Choice D, retinal detachment, is also not a typical complication of trachoma, as retinal detachment is usually caused by other factors such as trauma or age-related changes.
Question 5 of 5
The nurse is working in a primary care setting. Which clients should the nurse identify as being at high risk for influenza or its complications?Select the one that does not apply
Correct Answer: D
Rationale: In this scenario, option D, a 35-year-old man with a severe allergy to eggs, is the correct choice that does not apply as being at high risk for influenza or its complications. The rationale behind this is that the flu vaccine is traditionally grown in eggs, so people with severe egg allergies are advised against getting the standard flu shot. This makes the individual in option D less likely to be at risk for influenza complications compared to the other options. For options A, B, and C, they are at higher risk for influenza or its complications due to their specific circumstances. - Option A: Pregnant women are more susceptible to infections like influenza due to changes in their immune system during pregnancy. - Option B: Older adults, like the 65-year-old woman, have weaker immune systems, making them more vulnerable to severe flu symptoms. - Option C: Individuals with cystic fibrosis, like the 3-year-old in this case, often have compromised respiratory systems, which can lead to more severe complications if they contract the flu. Understanding these risk factors is crucial in nursing practice to provide targeted care and preventive measures for vulnerable populations. Nurses must be aware of these nuances in patient populations to tailor their interventions effectively and promote better health outcomes.