ATI RN
Skin Integrity and Wound Care Questions Questions
Question 1 of 5
Which intervention is important to reduce the effect of the diarrhea on Aaron's skin?
Correct Answer: A
Rationale: Correct Answer: A - Apply a moisture-repellent ointment on intact skin areas. Rationale: 1. Diarrhea can lead to skin breakdown due to moisture and irritation. 2. Moisture-repellent ointment forms a protective barrier on intact skin, preventing further damage. 3. Alcohol-based solutions can be drying and irritating to the skin. 4. Positioning a plastic-lined pad can help with cleanup but does not protect the skin. 5. Applying moist heat to the ear is unrelated to addressing skin issues caused by diarrhea.
Question 2 of 5
The nurse is caring for a client who is receiving IV antibiotics for the treatment of a Staphylococcus aureus infection. Which nursing interventions are appropriate when providing care to this client? Select the one that does not apply
Correct Answer: D
Rationale: The correct answer is D: Assess pain level. In this scenario, the client is receiving IV antibiotics for a Staphylococcus aureus infection, which is not typically associated with significant pain. The priority nursing interventions should focus on monitoring for allergic reactions due to antibiotic administration, assessing renal and liver function to ensure proper medication metabolism and excretion, and encouraging adequate fluid intake to prevent dehydration and support kidney function. Assessing pain level is not directly related to the treatment of Staphylococcus aureus infection with antibiotics and would not be a priority in this case.
Question 3 of 5
The nurse is caring for a client who is hospitalized for cellulitis of the foot. Which nursing diagnoses should the nurse use to plan this client's care? Select the one that does not apply
Correct Answer: A
Rationale: The correct answer is A: Social Isolation related to skin infection. Cellulitis primarily affects the physical aspect of the client's health, not their social interactions. The client's main concerns are related to the physical symptoms, such as impaired skin integrity, acute pain, and disturbed sleep pattern. These nursing diagnoses directly address the client's physical needs and promote healing. Social isolation is not directly related to cellulitis and would not be a priority nursing diagnosis in this case.
Question 4 of 5
The nurse is assessing a college student who presents with red, swollen eyes; photophobia; and yellowish drainage from the conjunctiva. Which question should the nurse ask the client first?
Correct Answer: D
Rationale: The correct question to ask the client first is D: "Have any of your friends experienced these symptoms?" This question helps identify if the symptoms are due to a contagious condition like conjunctivitis, commonly known as pink eye. By inquiring about friends' symptoms, the nurse can assess potential exposure and recommend appropriate precautions. Explanation for other choices: A: Asking about caffeine consumption is unrelated to the client's eye symptoms. B: Inquiring about sand in the eye is not relevant to the symptoms described. C: Asking about HIV exposure is not the priority as the symptoms presented are indicative of a different condition.
Question 5 of 5
The nurse is caring for a client who presents with acute malaise, muscle aches, and fever. Which additional assessment findings should the nurse recognize as consistent with influenza? Select the one that does not apply
Correct Answer: C
Rationale: The correct answer is C: Hypotension. Influenza typically presents with symptoms such as malaise, muscle aches, fever, and a nonproductive cough. Hypotension is not a common symptom of influenza. It is more indicative of other conditions like sepsis or dehydration. Difficulty urinating is not typically associated with influenza either. A lack of recent vaccinations (choice A) can contribute to susceptibility to influenza, and a nonproductive cough (choice B) is a common respiratory symptom seen in influenza cases. Thus, hypotension is the outlier among these assessment findings.