ATI LPN
Fundamentals Wound Care and Skin Integrity Questions Questions
Question 1 of 5
Which finding requires immediate referral when a nurse assesses an older adult's skin?
Correct Answer: B
Rationale: The lesion with various colors fits one of the American Cancer Society hallmark signs for cancer according to the ABCD method (color variation). This requires immediate referral.
Question 2 of 5
A nurse assesses a client who has burn injuries and notes crackles in bilateral lung bases, a respiratory rate of 40 breaths/min, and a productive cough with blood-tinged sputum. Which action should the nurse take next?
Correct Answer: D
Rationale: Pulmonary edema from fluid resuscitation can be relieved by placing the client upright.
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 patients body. Which action should the nurse take first?
Correct Answer: C
Rationale: The nurse should note irregular patterns of bruising, especially in the shapes of hands or fingers, in different stages of resolution. These may be indications of other health problems or abuse, and should be further investigated. It is important that the nurse interview the patient alone because, if mistreatment is occurring, the patient may not disclose it in the presence of the person who may be the abuser. Throw rugs and shoes with slippery surfaces may contribute to falls. X-rays may be needed if the patient has fallen recently and also has complaints of pain or decreased mobility. However, the nurses first nursing action is to further assess the patient.
Question 4 of 5
Which information will the nurse include when teaching an older patient about skin care?
Correct Answer: C
Rationale: Warm water and moisturizing soap will avoid overdrying the skin. Because older patients have dryer skin, daily bathing and shampooing are not necessary and may dry the skin unnecessarily. Antibacterial soaps are not necessary. Lotions should be applied while the skin is still damp to seal moisture in.
Question 5 of 5
The nurse is caring for a client with deep partial-thickness and full-thickness burns to the chest area. Which assessment data would warrant notifying the health-care provider?
Correct Answer: D
Rationale: Low urinary output (50 mL in 2 hours) suggests inadequate fluid resuscitation or renal compromise, requiring immediate provider notification.