ATI RN
Fundamentals of Nursing Skin Integrity Questions Questions
Question 1 of 5
Which activities can the nurse working in the outpatient clinic delegate to a licensed practical/vocational nurse (LPN/LVN) (select the one that does not apply)?
Correct Answer: D
Rationale: The correct answer is D because LPN/LVNs are not typically trained to explain medical tests to patients. LPN/LVNs can administer patch testing, interview patients, and apply sterile dressings under the supervision of a healthcare provider. Explaining medical tests requires a higher level of knowledge and skill, usually performed by registered nurses or healthcare providers. Therefore, delegating the task of explaining potassium hydroxide testing to an LPN/LVN would not be within their scope of practice.
Question 2 of 5
A child has been admitted to the burn unit after pulling a pan of hot water off the stove. Given the fact that there is primarily second- and third-degree burns, the health care worker should prioritize care to focus on which of the following? Select all that apply.
Correct Answer: A
Rationale: The correct answer is A: Focus on replacing fluids that have been lost from the vascular, interstitial, and cellular compartments. In burn injuries, there is a significant loss of fluids due to damage to the skin barrier. Prioritizing fluid replacement helps prevent hypovolemic shock and maintains adequate tissue perfusion. This is crucial in managing burn patients to prevent complications like organ failure. Choices B, C, and D are incorrect: B: Assessing for airway compromise is important but not the top priority in this scenario. Fluid resuscitation takes precedence in managing burn injuries. C: Maintaining a sterile field is important for infection prevention but is not the immediate priority over fluid replacement. D: Withholding nutrition is not recommended as burn injuries increase the body's metabolic demands. Providing adequate nutrition supports healing and recovery, so withholding food can be detrimental. In summary, fluid replacement is prioritized in burn injuries to prevent shock and maintain tissue perfusion.
Question 3 of 5
Which of the following changes are normal in the elderly population? Select all that apply.
Correct Answer: A
Rationale: Rationale for choice A being correct: The dermis and epidermis thin as one ages due to decreased collagen and elastin production. This leads to fragile skin, increased risk of injury, and slower wound healing. Summary of why other choices are incorrect: B: Subcutaneous tissue typically decreases with age, leading to less padding. C: Blood vessels tend to become less elastic and more rigid, not thicker. D: Older adults often experience muscle and fat loss, rather than increased padding on the buttocks.
Question 4 of 5
Which assessment finding indicates to the nurse that the patient is at high risk for developing a pressure injury?
Correct Answer: A
Rationale: A 'serum total protein level of 4.6 g/dL' flags high pressure injury risk, per Potter's *Essentials*. Normal is 6-8 g/dL; 4.6 e.g., 30% below causes edema, impairing oxygen delivery (e.g., 10% less to tissues), softening skin for breakdown. 'Braden Scale score of 22' is low risk e.g., 18 or below for elders signals danger, 22 is safe. 'Cetirizine 5 mg daily' is an antihistamine e.g., no skin integrity link. 'Fasting glucose 84 mg/dL' is normal e.g., 70-100, no risk. A nurse assessing e.g., swollen legs links low protein to 50% higher ulcer odds, per nutrition studies, needing dietary boost. is the correct, critical finding.
Question 5 of 5
Which intervention will the nurse use for an abscessed leg wound?
Correct Answer: C
Rationale: For an abscessed leg wound, 'warm moist compresses' suit, per Potter's . Heat e.g., 38°C boosts blood flow (e.g., 20% more), drawing pus e.g., drains in 24 hours unlike 'sitz baths' , for perineum e.g., post-hemorrhoid. 'Cold compresses' reduce swelling e.g., not drainage. 'Epsom soaks' relax muscles e.g., not abscess-specific. A nurse applies e.g., Warm cloth 15 min' aiding resolution (e.g., 70% faster), per heat therapy principles. Potter notes warmth's circulatory aid, a physiological integrity boost, making the correct, therapeutic choice.