ATI RN
NCLEX Skin Integrity Questions Questions
Question 1 of 5
Which diagnostic test result is consistent with a diagnosis of septic shock?
Correct Answer: B
Rationale: The correct answer is B because a hematocrit that is higher than normal is consistent with septic shock due to hemoconcentration from fluid shifting out of the blood vessels. A higher hematocrit indicates dehydration and decreased blood volume, which are common in septic shock. A is incorrect because septic shock typically results in metabolic acidosis, leading to a lower blood pH. C is incorrect because septic shock can lead to respiratory alkalosis, resulting in higher PaCO2 levels. D is incorrect because septic shock often leads to hyperkalemia, causing potassium levels to be higher than normal.
Question 2 of 5
A nurse is caring for a client with tuberculosis (TB) who is taking rifampin for treatment of the disease. Which nursing interventions are appropriate for this client? Select all that apply.
Correct Answer: C
Rationale: The correct answer is C: Administer the medication on an empty stomach. Rifampin should be administered on an empty stomach to enhance absorption. Taking it with meals reduces absorption. A: Administering with meals is incorrect as it reduces absorption. B: Recording a baseline visual examination is not specific to rifampin therapy. D: Administering by deep intramuscular injection is unnecessary and not recommended for rifampin administration. In summary, the correct answer is C because it optimizes medication absorption.
Question 3 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 patient’s body. Which action should the nurse take first?
Correct Answer: C
Rationale: Step 1: Talking with the patient alone allows for open communication and assessment of the situation. Step 2: Asking about the bruising can provide insight into the cause, such as potential abuse or neglect. Step 3: It is essential to gather information directly from the patient to ensure their safety and well-being. Step 4: This action prioritizes the patient's autonomy and right to disclose information. It also demonstrates a patient-centered approach. Summary: Option C is correct because it focuses on communication and assessment to address potential safety concerns. Options A and B address fall prevention, which is not the immediate concern. Option D jumps to radiographs without understanding the situation.
Question 4 of 5
Which information should the nurse include when teaching patients about decreasing the risk for sun damage to the skin?
Correct Answer: B
Rationale: The correct answer is B: Try to stay out of the direct sun between the hours of 10 AM and 2 PM. This is correct because UV radiation is strongest during these hours, so avoiding direct sun exposure at this time can significantly reduce the risk of sun damage. Choice A is incorrect because an SPF of at least 30 is recommended for adequate protection. Choice C is incorrect because water-resistant sunscreens may provide some protection but should be reapplied after swimming. Choice D is incorrect as increasing sun exposure can lead to skin damage rather than decrease the risk.
Question 5 of 5
A patient with atopic dermatitis has been using a high-potency topical corticosteroid ointment for several weeks. The nurse should assess for which adverse effect?
Correct Answer: A
Rationale: The correct answer is A: Thinning of the affected skin. High-potency topical corticosteroids can lead to skin atrophy, causing thinning of the skin with prolonged use. This adverse effect is important to assess for as it can increase the risk of skin fragility and potential for skin tears or bruising. Choice B: Alopecia of the affected areas is not typically associated with the use of topical corticosteroids, so it is an incorrect choice. Choice C: Dryness and scaling are common symptoms of atopic dermatitis itself, not directly caused by the corticosteroid ointment, making this choice incorrect. Choice D: Reddish-brown skin discoloration is not a common adverse effect of topical corticosteroids and is not typically seen with their use, making this choice incorrect.