ATI RN
Fundamentals of Nursing Skin Integrity Questions Questions
Question 1 of 5
Which areas are most important for the nurse to observe for additional pressure ulcers?
Correct Answer: C
Rationale: The correct answer is C, heels and ankles. These areas are most prone to pressure ulcers due to prolonged pressure when sitting or lying down. Gravity and body weight make these areas susceptible to poor blood circulation and tissue damage. Observing the heels and ankles is crucial for early detection and prevention of pressure ulcers. The other choices (A, B, D) are less common areas for pressure ulcers and may not be as affected by prolonged pressure compared to the heels and ankles.
Question 2 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 3 of 5
The healthcare provider prescribes a client to have peak and trough blood levels drawn to evaluate the therapeutic effect of an IV antibiotic. When should the nurse schedule the blood samples to be drawn?Select the one that does not apply
Correct Answer: A
Rationale: The correct answer is A. Peak levels are drawn 30 minutes after the IV infusion, while trough levels are drawn just before the next dose is given, so B is incorrect. Drawing blood during the infusion, as in C, would not provide accurate peak or trough levels. Drawing blood 30 minutes after administration, as in D, is not specifically timed for peak or trough levels. Drawing blood before discontinuing the antibiotic, as in A, ensures accurate trough levels and helps assess the drug's effectiveness.
Question 4 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 5 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.