ATI RN
Fundamentals of Nursing Skin Integrity Questions Questions
Question 1 of 5
What is the primary rationale for maintaining adequate hydration in clients with pneumonia?
Correct Answer: D
Rationale: The correct answer is D because adequate hydration helps keep the airway clear by making secretions easier to expectorate. Proper hydration thins mucus secretions, making it easier for clients with pneumonia to cough up and clear their airways, reducing the risk of respiratory complications. Maintaining hydration does not primarily affect urine output (A), blood pressure (B), or mucus membrane moisture (C) in clients with pneumonia.
Question 2 of 5
The nurse is providing discharge teaching for a client diagnosed with a urinary tract infection (UTI). The client is prescribed a 3-day course of oral trimethoprim-sulfamethoxazole (TMP-SMZ). Which client statement indicates that teaching has been effective?
Correct Answer: A
Rationale: The correct answer is A. The client's statement indicates understanding of the importance of follow-up urine culture after completing antibiotic treatment for a UTI to ensure eradication of the infection. This shows compliance with medical advice and monitoring treatment efficacy. Choice B (Kegel exercises) is irrelevant to UTI treatment. Choice C (increasing fluid intake) is a general good practice but not specific to UTI treatment. Choice D (wearing cotton underwear) is not directly related to UTI treatment.
Question 3 of 5
The charge nurse for a medical-surgical unit is notified that a client with tuberculosis (TB) is being transported to the unit. Which actions for infection prevention are the most appropriate in this circumstance? Select all that apply.
Correct Answer: B
Rationale: The correct answer is B because wearing a respirator and gown when caring for a client with TB is essential to prevent the spread of the disease through respiratory droplets. This protective equipment helps to minimize the risk of healthcare workers inhaling the TB bacteria. Choice A is incorrect because stocking the client's supply cart does not directly address infection prevention for TB. Choice C is incorrect because having the client wear a mask is not as effective as the healthcare provider wearing personal protective equipment. Choice D is incorrect because hand hygiene should be performed both before and after caring for the client with TB to prevent the spread of infection.
Question 4 of 5
The nurse assesses a circular, flat, reddened lesion about 5 cm in diameter on a middle-aged patient’s ankle. How should the nurse determine if the lesion is related to intradermal bleeding?
Correct Answer: B
Rationale: The correct answer is B: Press firmly on the lesion. By pressing firmly on the lesion, the nurse can assess if the reddened area blanches (turns white) temporarily, indicating intradermal bleeding. Elevating the leg (choice A) may help with circulation but does not directly assess intradermal bleeding. Checking skin temperature (choice C) does not provide information about intradermal bleeding. Palpating pulses (choice D) assesses vascular status but does not directly assess intradermal bleeding. Pressing firmly on the lesion is the most direct way to determine if the redness is related to intradermal bleeding.
Question 5 of 5
The nurse notes darker skin pigmentation in the skinfolds of a middle-aged patient who has a body mass index of 40 kg/m2. What is the nurse’s appropriate action?
Correct Answer: D
Rationale: The correct answer is D: Ask the patient about a personal or family history of type 2 diabetes. This is important because individuals with darker skin pigmentation and obesity are at higher risk for developing type 2 diabetes. By inquiring about the patient's personal or family history of type 2 diabetes, the nurse can gather important information to assess the patient's risk factors and potentially intervene early. Summary of other choices: A: Discussing the use of drying agents to minimize infection risk may not address the underlying health concern related to darker skin pigmentation and obesity. B: Instructing the patient about the use of mild soap to clean skinfolds is important for hygiene but does not address the potential risk of type 2 diabetes. C: Teaching the patient about treating fungal infections in the skinfolds may be relevant if there is a current infection but does not address the broader health implications of darker skin pigmentation and obesity.