ATI RN
NCLEX Skin Integrity Questions Questions
Question 1 of 5
Which interventions should the nurse incorporate into the plan of care for a client diagnosed with influenza? Select the one that does not apply
Correct Answer: B
Rationale: Correct Answer: B - Placing the client in a negative air flow room does not apply. Influenza is primarily spread through respiratory droplets and contact, not airborne transmission. Therefore, a negative air flow room is not necessary. Rationale: A: Placing droplet and contact precaution signs is important to alert staff and visitors to take necessary precautions. C: Placing a ventilator is not necessary for influenza treatment, as it is a respiratory infection, not a condition requiring mechanical ventilation. D: Notifying other departments is crucial for infection control and prevention, to ensure appropriate measures are taken to prevent the spread of influenza.
Question 2 of 5
The nurse is caring for an older adult client who is hospitalized with a second episode of pneumonia in the past 18 months. The client has expressed frustration to the nurse and states, 'I never got sick when I was younger. Why is this happening?' Which response by the nurse is most appropriate?
Correct Answer: B
Rationale: The correct answer is B because as individuals age, there is a natural decline in the immune response known as immunosenescence. This leads to a decreased ability to fight off infections like pneumonia, making older adults more susceptible. Option A is incorrect as the immune system doesn't simply stop working with age. Option C is incorrect because aging actually leads to a decline in immune response speed and strength. Option D is incorrect as an increase in B cells would not hinder the immune response but rather indicates a potential boost in antibody production.
Question 3 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 4 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 5 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