ATI RN
NCLEX Skin Integrity Questions Questions
Question 1 of 5
Which instruction should the nurse provide to an adolescent client with otitis media with regard to pain?
Correct Answer: B
Rationale: The correct answer is B: Report abrupt relief of pain immediately. This instruction is important because sudden relief of pain in otitis media may indicate rupture of the eardrum, which requires immediate medical attention. Applying a cold compress (A) may provide temporary relief but does not address the underlying issue. Continuing air travel (C) can worsen otitis media due to changes in air pressure. Reporting increased pain when moving the outer ear (D) may indicate an external ear infection, not specific to otitis media.
Question 2 of 5
A client is admitted to the intensive care unit with a systemic infection. Which manifestations will the nurse most likely assess in this client? Select all that apply.
Correct Answer: D
Rationale: The correct answer is D: Hypotension. In systemic infection, the body's response often leads to widespread inflammation and vasodilation, resulting in decreased blood pressure. This can lead to hypotension due to decreased vascular resistance. Tachycardia (A) may also be present as the body compensates for low blood pressure by increasing heart rate. Pain (B) and Edema (C) are less likely to be directly associated with systemic infection and are not typical manifestations.
Question 3 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 4 of 5
The healthcare provider prescribes an indwelling urinary catheter for a client with urinary retention. Which intervention, along with strict aseptic technique, will decrease the risk of infection for this procedure?
Correct Answer: C
Rationale: Correct Answer: C - Using an anesthetic lubricating gel during insertion Rationale: Using an anesthetic lubricating gel during catheter insertion helps to reduce discomfort and trauma to the urethral mucosa, decreasing the risk of infection. This gel also helps to facilitate a smoother insertion process, reducing the chances of introducing pathogens into the urethra. Strict aseptic technique is important to prevent infection but using the lubricating gel specifically addresses the risk of trauma and discomfort during catheterization. Incorrect Choices: A: Irrigating the catheter with sterile saline on a daily basis - While irrigation with sterile saline is important for maintaining catheter patency, it does not directly decrease the risk of infection during catheter insertion. B: Instructing the client to void around the catheter - This does not address the risk of infection during catheter insertion; it is important for proper catheter care post-insertion. D: Inflating the balloon while the catheter is in
Question 5 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.