ATI LPN
Fundamentals Wound Care and Skin Integrity Questions Questions
Question 1 of 5
When examining an older patient in the home, the home health nurse notices irregular patterns of bruising at different stages of healing on the patients body. Which action should the nurse take first?
Correct Answer: C
Rationale: The nurse should note irregular patterns of bruising, especially in the shapes of hands or fingers, in different stages of resolution. These may be indications of other health problems or abuse, and should be further investigated. It is important that the nurse interview the patient alone because, if mistreatment is occurring, the patient may not disclose it in the presence of the person who may be the abuser. Throw rugs and shoes with slippery surfaces may contribute to falls. X-rays may be needed if the patient has fallen recently and also has complaints of pain or decreased mobility. However, the nurses first nursing action is to further assess the patient.
Question 2 of 5
The nurse is caring for a client with deep partial-thickness and full-thickness burns to the chest area. Which assessment data would warrant notifying the health-care provider?
Correct Answer: D
Rationale: Low urinary output (50 mL in 2 hours) suggests inadequate fluid resuscitation or renal compromise, requiring immediate provider notification.
Question 3 of 5
The nurse and an unlicensed assistive personnel (UAP) are caring for clients in a dermatology clinic. Which task should not be delegated to the UAP?
Correct Answer: C
Rationale: Discussing client problems requires nursing judgment, beyond the UAP's scope.
Question 4 of 5
Which intervention should the nurse implement for a client diagnosed with disseminated herpes zoster secondary to AIDS?
Correct Answer: A
Rationale: Disseminated herpes zoster in AIDS requires contact isolation to prevent transmission due to immunocompromise.
Question 5 of 5
Which client signs and symptoms indicate contact dermatitis to the nurse?
Correct Answer: A
Rationale: Contact dermatitis typically presents with erythema and oozing vesicles due to an allergic reaction.