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ATI LPN FUNDAMENTALS EXAM I
Total Questions : 39
Showing 10 questions, Sign in for moreA nurse is caring for a client who has a large surgical wound healing by secondary intention. The nurse should recommend a diet high in protein and which of the following nutrients?
A nurse is caring for a client who has a stage-3 pressure ulcer that now has some granulating tissue. Which of the following interventions should the nurse recommend for inclusion in the plan of care?
A nurse is collecting data on a client. Which of the following findings increase the client's risk for developing a pressure injury?
A nurse is collecting data on client who has a heart rate of 56/min. Which of the following findings should the nurse expect?
A nurse is caring for an older adult client who is at risk for skin breakdown. Which of the following interventions should the nurse use to help maintain the client's skin integrity?
A nurse is measuring an adult client's tympanic temperature. Which of the following actions should the nurse take?
A nurse is collecting data on a client to check for orthostatic hypotension. Which of the following actions should the nurse take first?
A nurse is caring for a client who has urinary incontinence. Which of the following actions should the nurse take to prevent the development of skin breakdown?
Click to highlight the findings that require follow-up. To deselect a finding, click on the finding again.
Wound bed is red.
Redness noted at wound borders, skin surrounding wound is warm to touch
purulent drainage noted
Temp 38.9° C (102° F)
Hct 37% (37% to 47%)
WBC 13,500/mm3 (5000 to 10,000 mm3)
Explanation
The findings that require follow-up:
- Redness noted at wound borders, skin surrounding wound is warm to touch
This suggests local infection or inflammation around the wound. - Purulent drainage noted
Purulent (thick, discolored) drainage is a sign of infection and requires prompt follow-up. - Temp 38.9° C (102° F)
This elevated temperature indicates a systemic response, likely due to infection. - WBC 13,500/mm³ (5000 to 10,000 mm³)
This is an elevated WBC count, consistent with infection or inflammation.
Incorrect answers:
- Wound bed is red
A red wound bed in a pressure injury is often a sign of granulation tissue, which is part of the normal healing process, not a concern unless accompanied by other signs of infection. - Hct 37% (37% to 47%)
Hematocrit is within normal limits, and does not indicate concern.
A nurse is collecting data on a client who has a stage 1 pressure injury. Which of the following findings should the nurse expect?
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