ATI RN
Fundamentals of Nursing Skin Integrity Questions Questions
Question 1 of 5
Which of the following best describes an unintentional wound?
Correct Answer: B
Rationale: Jagged wound edges, uncontrolled bleeding' describes an unintentional wound, . Accidents e.g., falls tear e.g., 2 cm, 50 mL unlike 'clean edges' or 'low infection risk' , surgical e.g., planned. 'Surgery, IV' is intentional e.g., not accidental. A nurse sees e.g., Rough, bloody' per trauma type, a physiological distinction. The text contrasts this with intentional, making the correct, unintentional descriptor.
Question 2 of 5
A nurse is teaching a patient on home care how to apply hot packs to an infected leg ulcer. What statement by the patient indicates the need for further teaching?
Correct Answer: D
Rationale: I will leave the heat packs on for an hour' needs teaching. Heat e.g., 20-30 min boosts flow e.g., 50% healing beyond risks burns e.g., 60 min, 10% chance unlike 'rebound effect' , correct e.g., vasoconstriction. 'Only on sore' and '20 minutes' align e.g., safe. A nurse reteaches e.g., Short heat' per guidelines, a physiological must. The text limits duration, making the correct, error signal.
Question 3 of 5
Which areas are most important for the nurse to observe for additional pressure ulcers?
Correct Answer: C
Rationale: The correct answer is C, heels and ankles. These areas are most prone to pressure ulcers due to prolonged pressure when sitting or lying down. Gravity and body weight make these areas susceptible to poor blood circulation and tissue damage. Observing the heels and ankles is crucial for early detection and prevention of pressure ulcers. The other choices (A, B, D) are less common areas for pressure ulcers and may not be as affected by prolonged pressure compared to the heels and ankles.
Question 4 of 5
What action should the nurse take regarding the positioning schedule?
Correct Answer: A
Rationale: The correct answer is A because providing verbal instructions to the UAP ensures clear communication, which is crucial for consistent care. Documenting the instructions in the nurse's notes helps track the care provided. Choice B involves unnecessary escalation and may not be efficient. Choice C is incorrect as client confidentiality is always a priority. Choice D overlooks the importance of direct communication and documentation in ensuring proper care.
Question 5 of 5
What teaching should the nurse provide regarding Aaron's ulcer with granulation tissue?
Correct Answer: B
Rationale: The correct answer is B. Hydrocolloid dressings should be continued over the ulcer because they provide a moist environment that promotes granulation tissue formation and wound healing. Antibiotics may not be necessary if there is no sign of infection. Debridement may not be needed if the granulation tissue is healthy. Keeping the ulcer open to the air can lead to dryness and hinder the healing process.