ATI RN
Fundamentals of Nursing Skin Integrity Questions Questions
Question 1 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 2 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 3 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 4 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.
Question 5 of 5
The nurse is teaching the mother of an infant with otitis media to manage the associated fever and pain. Which instruction by the nurse is correct?
Correct Answer: C
Rationale: Correct Answer: C - Administer acetaminophen. Rationale: 1. Acetaminophen is an appropriate medication for reducing fever and relieving pain in infants with otitis media. 2. Swaddling the baby in blankets may increase body temperature and discomfort. 3. Feeding solid foods is not recommended during illness, as infants may have difficulty swallowing or digesting. 4. Bathing the baby with cool water may cause chills and discomfort, worsening the condition. In summary, administering acetaminophen is the correct choice as it addresses both fever and pain effectively, while the other options may exacerbate the infant's condition.