ATI RN
Skin Integrity and Wound Care Questions Questions
Question 1 of 5
When patients are pulled up in bed rather than lifted, they are at increased risk for the development of a decubitus ulcer. What is the name given to the factor responsible for this risk?
Correct Answer: D
Rationale: Shearing force' increases ulcer risk when pulled. Sliding e.g., 45° tears vessels e.g., 50% ischemia unlike 'friction' , surface e.g., abrasion. 'Necrosis' is result e.g., not cause. 'Ischemia' follows e.g., effect. A nurse notes e.g., Shear damage' per 60% risk boost, a physiological factor. The text names shearing, making the correct, risk-naming term.
Question 2 of 5
The sacral area has remained red for two hours and does not blanch when tested. How will the nurse document this finding?
Correct Answer: D
Rationale: The correct answer is D: Reactive hyperemia. This term refers to the redness that persists after pressure is relieved due to increased blood flow to the area. In this case, the sacral area remaining red for two hours and not blanching indicates reactive hyperemia. A: Excessive pallor is incorrect as pallor refers to paleness, not redness. B: Unusual skin mottling is incorrect as mottling refers to irregular patches of skin discoloration, not persistent redness. C: Dependent sacral rubor is incorrect as rubor refers to redness due to increased blood flow, but it does not explain the persistence of redness and lack of blanching.
Question 3 of 5
Which intervention is important to reduce the effect of the diarrhea on Aaron's skin?
Correct Answer: A
Rationale: Correct Answer: A - Apply a moisture-repellent ointment on intact skin areas. Rationale: 1. Diarrhea can lead to skin breakdown due to moisture and irritation. 2. Moisture-repellent ointment forms a protective barrier on intact skin, preventing further damage. 3. Alcohol-based solutions can be drying and irritating to the skin. 4. Positioning a plastic-lined pad can help with cleanup but does not protect the skin. 5. Applying moist heat to the ear is unrelated to addressing skin issues caused by diarrhea.
Question 4 of 5
The nurse encourages Aaron to select which breakfast items to provide a good source of protein?
Correct Answer: D
Rationale: The correct answer is D, eggs and orange juice. Eggs are an excellent source of high-quality protein. They provide essential amino acids needed for growth and repair of body tissues. Orange juice is a good source of vitamin C, which helps with the absorption of iron from eggs. Whole wheat toast with butter (A) and bagels with cream cheese (B) are higher in carbohydrates and fats, not protein. Oatmeal and a banana (C) are healthy options but do not provide as much protein as eggs.
Question 5 of 5
The nurse is caring for a client who is receiving IV antibiotics for the treatment of a Staphylococcus aureus infection. Which nursing interventions are appropriate when providing care to this client? Select the one that does not apply
Correct Answer: D
Rationale: The correct answer is D: Assess pain level. In this scenario, the client is receiving IV antibiotics for a Staphylococcus aureus infection, which is not typically associated with significant pain. The priority nursing interventions should focus on monitoring for allergic reactions due to antibiotic administration, assessing renal and liver function to ensure proper medication metabolism and excretion, and encouraging adequate fluid intake to prevent dehydration and support kidney function. Assessing pain level is not directly related to the treatment of Staphylococcus aureus infection with antibiotics and would not be a priority in this case.