ATI LPN
Fundamentals of Nursing Care: Concepts, Connections & Skills
Chapter 26 : Wound Care Questions
Question 1 of 5
A patient has signs of infection in his left shoulder incision-erythema, warmth, and a small amount of purulent drainage. You prepare to report this to the health-care provider. Which information will you have ready when you call?
Correct Answer: A,C,E,G
Rationale: Vital signs, lab results, wound description, and infection signs are critical for the provider to assess and plan treatment.
Question 2 of 5
You are caring for a 67-year-old male who had a cerebrovascular accident 3 weeks ago. In addition, he has developed a pressure injury on his right hip. Which of the following data that you collected will be useful in developing a care plan that will address his pressure ulcer?
Correct Answer: A,B,D,E
Rationale: When developing a care plan for a 67-year-old male with a pressure injury, several pieces of collected data are particularly useful. His weight loss from 165.5 to 161.8 pounds over the past week suggests nutritional deficits, which can impair wound healing and should be addressed through dietary interventions. The identification of the pressure injury as stage 3 indicates full-thickness tissue damage and guides the level of wound care required, such as debridement and specialized dressings. His inability to sit in a chair for more than 15 minutes highlights limited mobility, a major risk factor for pressure ulcers, requiring repositioning schedules and pressure-relieving devices. Additionally, while he dislikes some high-protein foods like cheese, beans, chicken, and fish, his preference for steak, eggs, nuts, and peanut butter still offers adequate protein options, which are critical for tissue repair and wound healing. These preferences should be incorporated into his care plan to ensure compliance with nutritional recommendations.
Question 3 of 5
Which one of the following interventions would you rateas the most important for care of his pressure injury?
Correct Answer: C
Rationale: Frequent repositioning is the most critical intervention in preventing further skin breakdown and promoting healing of pressure injuries. Since the wound is on his right hip, avoiding the right lateral position helps reduce pressure on the affected area, improving circulation and tissue recovery. This intervention directly addresses pressure relief, which is the primary cause of pressure injuries.
Question 4 of 5
A patient's J-P drain should be emptied:
Correct Answer: C
Rationale: A J-P drain should be emptied when one-half to two-thirds full to maintain proper suction and prevent complications.
Question 5 of 5
Which one of the following assessment findings makes it impossible to stage a pressure injury?
Correct Answer: B
Rationale: Eschar obscures the wound bed, making it impossible to assess the depth and stage of a pressure injury.