Practice Question
A nurse is caring for a client that is immobile. The nurse recognizes that the appearance of non-blanchable erythema on the heels most likely indicates which of the following stages of pressure injuries?
Answer Choices:
Correct Answer:
Stage I pressure injury
Rationale:
🟢 Non-blanchable erythema of intact skin is the defining feature of a Stage I pressure injury.
🟢 The skin may feel warmer or cooler, and clients may report pain or discomfort.
🟢 No open wound or skin loss is present at this stage.
🟢 Immediate intervention prevents progression to deeper tissue damage.
🟢 Risk factors include immobility, moisture, and poor nutrition.
🟢 This is the earliest detectable stage and is completely reversible if treated early.
Want to practice more questions like this?
This question is from ATI Medsurg Cohort 6 Exam which contains 47 questions.
More Questions from This Exam
A nurse teaches a patient who is at risk for mild hypernatremia. Which statement does the nurse include in this patient's teaching?
Answer Choices:
A. "Bake or grill the meat rather than frying it."
B. “Check your radial pulse twice a day.”
C. "Read food labels to determine sodium content."
D. “Weigh yourself every morning and every night."
A nurse is caring for a client with an electrical burn. The client states that since the wound on the skin is small, the burn must not be too bad. Which of the following is the best response by the nurse?
Answer Choices:
A. Electrical burns can have small amounts of skin damage, but more extensive damage beneath the skin.
B. Electrical burns commonly cause reddened/purplish skin without blistering.
C. Electrical burns typically are minor.
D. Electrical burns usually cause much more skin damage than what can be seen on your skin.
A nurse is caring for a client who has sustained a gasoline burn to 25% of the body. Which of the following is a priority safety concern when caring for this client?
Answer Choices:
A. Elevation of the head of the bed by 30 degrees
B. Determining the amount of gasoline that the client encountered
C. Asking the client when they last ate a meal
D. Decontamination of the client
A nurse is caring for a client with a pressure injury. Which of the following should the nurse recognize as a priority in the plan of care?
Answer Choices:
A. Keeping the wound clean and non-infected
B. Application of a negative pressure wound care device
C. Client education on wound prevention
D. Promoting a high carbohydrate, low protein diet
The nurse takes a client's temperature before giving a blood transfusion. The temperature is 100 F orally. The nurse reports the finding to the registered nurse (RN) and anticipates that which action will take place?
Answer Choices:
A. The transfusion will begin after the administration of 650 mg of acetaminophen {Tylenol).
B. The blood will be held, and the health care provider will be notified
C. The transfusion will begin after the administration of an antihistamine
D. The transfusion will begin as prescribed
Question Details
- Category: LPN Nursing Exam(s)
- Subcategory: LPN ATI Exams
- Domain: Medical-Surgical
- Answer Choices: 4