ATI RN
Fundamentals of Nursing Skin Integrity Questions Questions
Question 1 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 2 of 5
The patient has a deep decubitus ulcer on the heel that is covered in thick necrotic tissue. Which term will the nurse use to describe the ulcer in the patient's medical record?
Correct Answer: D
Rationale: A heel ulcer with thick necrosis is 'unstageable' , per Potter's. Depth's hidden e.g., eschar blocks view unlike 'fluctuant' , shifting e.g., abscess fluid. 'Indurated' is hard e.g., not necrotic. 'Macerated' is wet e.g., moisture breakdown. A nurse writes e.g., Black cover' unstageable's 15% rate, per NPUAP, needing debridement. Potter notes obscured depth blocks staging e.g., not Stage 4 till cleared a physiological integrity issue. is the correct, assessment term.
Question 3 of 5
The nurse is caring for a group of patients. Which patient will the nurse see first?
Correct Answer: C
Rationale: The nurse prioritizes 'a patient with appendicitis using a heating pad'. Heat risks rupture e.g., 10% chance in 24 hours unlike 'Stage IV ulcer' , serious but stable e.g., managed. 'Braden score 18' is low risk e.g., >16 safe. 'Approximated incision' is normal e.g., no urgency. A nurse acts e.g., Remove heat' per acute inflammation rules, a physiological emergency. The text flags heat's danger, making the correct, urgent priority.
Question 4 of 5
The nurse is caring for a patient with a healing Stage III pressure ulcer. Upon entering the room, the nurse notices an odor and observes a purulent discharge, along with increased redness at the wound site. What is the next best step for the nurse?
Correct Answer: A
Rationale: The next best step is 'complete the head-to-toe assessment'. Odor and pus e.g., infection signs need full data e.g., temp 38.5°C, WBC 15,000 unlike 'notify provider' , premature e.g., needs facts. 'Consult wound nurse' and 'check charge nurse' follow e.g., not first. A nurse assesses e.g., Fever, drainage' per 80% infection protocol, a physiological must. The text mandates full assessment first, making the correct, thorough step.
Question 5 of 5
The nurse is completing an assessment of the patient's skin's integrity. Which assessment is the priority?
Correct Answer: A
Rationale: Pressure points' are priority in skin integrity assessment. Bony prominences e.g., heels risk ulcers e.g., 60% of cases unlike 'breath sounds' , respiratory e.g., not skin. 'Bowel sounds' track digestion e.g., indirect. 'Pulse points' check flow e.g., secondary. A nurse inspects e.g., Sacrum red' per visual/tactile need, a physiological must. The text emphasizes pressure sites, making the correct, top focus.