ATI LPN
Integumentary System Questions Questions
Question 1 of 5
What is the scientific rationale for placing lift pads under an immobile client?
Correct Answer: D
Rationale: The correct answer is D because lift pads help prevent friction shearing when repositioning an immobile client. Friction shearing occurs when two surfaces rub against each other, causing damage to the skin and underlying tissues. Lift pads provide a smooth surface that reduces friction, minimizing the risk of skin breakdown and pressure ulcers. Choice A is incorrect because lift pads are not designed to absorb bodily fluids. Choice B is incorrect because lift pads do not prevent diaphoresis (excessive sweating). Choice C is incorrect because the primary purpose of lift pads is not to prevent workplace injuries for staff, although they may contribute to reducing the risk of musculoskeletal injuries.
Question 2 of 5
The long-term care nurse has received the a.m. shift report. Which client should the nurse assess first?
Correct Answer: C
Rationale: The correct answer is C because periorbital skin lesions could indicate a serious issue like an infection or skin condition that requires immediate attention to prevent complications. Assessing this client first is crucial to address potential health risks. Choice A is not the priority as not having a bowel movement today may not be an urgent concern if the client is not experiencing discomfort or other symptoms. Choice B could be important but changing an indwelling catheter can typically wait a bit longer without immediate harm. Choice D, a stage I pressure ulcer, is concerning but usually does not require immediate attention compared to a potential skin infection indicated by periorbital lesions.
Question 3 of 5
The public health nurse is caring for a client diagnosed with leprosy (Hansen's disease). Which intervention should the nurse implement?
Correct Answer: D
Rationale: The correct answer is D. It is crucial to educate the client about how leprosy is transmitted to prevent further spread. Hospital admission may not be necessary for all cases. Administering dapsone for only one month is insufficient for treating leprosy. Using moisturizing lotion does not address the transmission of the disease. Therefore, discussing transmission methods is the priority intervention.
Question 4 of 5
A client is undergoing fluid replacement after being burned on 20% of her body 12 hours ago. The nursing assessment reveals a blood pressure of 90/50 mm Hg, a pulse rate of 110 beats/minute, and a urine output of 20 mL over the past hour. The nurse reports the findings to the health care provider (HCP) and anticipates which prescription?
Correct Answer: C
Rationale: The correct answer is C: Increasing the amount of intravenous (IV) lactated Ringer's solution administered per hour. This is the most appropriate action to address the client's hypovolemia due to burn injury. The client's low blood pressure, tachycardia, and decreased urine output indicate inadequate fluid resuscitation. Increasing the IV fluid rate will help improve perfusion and fluid balance. Option A (Transfusing 1 unit of packed red blood cells) is incorrect because the client's low blood pressure is likely due to hypovolemia rather than anemia. Option B (Administering a diuretic to increase urine output) is contraindicated as the client is already hypovolemic and needs fluid resuscitation. Option D (Changing the IV lactated Ringer's solution to one that contains 5% dextrose in water) is not appropriate as the primary concern is to address hypovolemia rather than providing additional
Question 5 of 5
For a client diagnosed with lumbar strain, which nursing interventions should be included in the plan of care?
Correct Answer: A
Rationale: Step 1: Assessing pain on a 1-to-10 scale is crucial in managing lumbar strain as it helps determine the severity and effectiveness of interventions. Step 2: Pain assessment guides treatment adjustments and ensures optimal pain control for the client. Step 3: Administering pain medication PRN without proper assessment may lead to overmedication or under-treatment. Step 4: Providing a regular bedpan for elimination is not directly related to managing lumbar strain. Step 5: Assessing surgical dressing every four hours is not necessary for a client with lumbar strain unless there are specific indications.