ATI RN
Fundamentals of Nursing Skin Integrity Questions Questions
Question 1 of 5
What intervention should be included on a plan of care to prevent pressure ulcer development in healthcare settings?
Correct Answer: B
Rationale: Implement a turning schedule every 2 hours' prevents ulcers. Q2h e.g., 30° lateral cuts pressure e.g., <32 mmHg unlike 'once per shift' , too long e.g., 8 hr risk. 'Ring cushions' pinch e.g., contraindicated. 'No turn, support surface' lacks e.g., needs both. A nurse plans e.g., Turn q2h' per 80% prevention, a physiological must. The text mandates this, making the correct, key intervention.
Question 2 of 5
Which areas are most important for the nurse to observe for additional pressure ulcers?
Correct Answer: C
Rationale: The correct answer is C, heels and ankles. These areas are most prone to pressure ulcers due to prolonged pressure when sitting or lying down. Gravity and body weight make these areas susceptible to poor blood circulation and tissue damage. Observing the heels and ankles is crucial for early detection and prevention of pressure ulcers. The other choices (A, B, D) are less common areas for pressure ulcers and may not be as affected by prolonged pressure compared to the heels and ankles.
Question 3 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 4 of 5
What teaching should the nurse provide regarding Aaron's ulcer with granulation tissue?
Correct Answer: B
Rationale: The correct answer is B. Hydrocolloid dressings should be continued over the ulcer because they provide a moist environment that promotes granulation tissue formation and wound healing. Antibiotics may not be necessary if there is no sign of infection. Debridement may not be needed if the granulation tissue is healthy. Keeping the ulcer open to the air can lead to dryness and hinder the healing process.
Question 5 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.