ATI RN
Skin Integrity and Wound Care Questions Questions
Question 1 of 5
A 44-year-old man has been brought to the emergency department with severe electrical burns resulting from a workplace accident. The most immediate threat to this client's survival at this time is:
Correct Answer: B
Rationale: The correct answer is B: Hemodynamic instability. In severe electrical burns, the most immediate threat is hemodynamic instability due to fluid shifts and potential cardiac arrhythmias. This can lead to shock and organ failure. Addressing hemodynamic stability is crucial to prevent further complications. Choice A: Infection is a concern in burn injuries but is not the most immediate threat to survival in this case. Choice C: Acute pain is important to manage but does not pose an immediate threat to survival. Choice D: Decreased protein synthesis and impaired healing are long-term consequences of burns and not the most immediate threat to survival in this scenario.
Question 2 of 5
Which factor contributes to pressure injury formation when patient's body slides downward to the foot of the bed?
Correct Answer: D
Rationale: Shearing force' drives pressure injury when a patient slides down in bed, per Potter's *Essentials*. Shear occurs as skin sticks to sheets while bones slide e.g., elevating head 30° pulls skeleton down 10 cm tearing capillaries, unlike 'momentum' , motion's force e.g., a rolling ball, not skin-specific. 'Acceleration' is speed gain e.g., falling, not sliding. 'Applied force' is generic e.g., pushing, not shear's dual-plane action. A nurse sees e.g., sacral redness after 2 hours shear's friction (e.g., 40% of bedbound cases), needing repositioning. Potter notes gravity's pull against stationary skin doubles injury risk vs. pressure alone, a reduction-of-risk focus. is the correct, mechanistic factor.
Question 3 of 5
Which is the first intervention of the nurse for changing the dressing to a painful burn?
Correct Answer: A
Rationale: For a painful burn dressing change, 'administer pain medication 30 minutes beforehand' is first, per Potter's *Essentials*. Analgesia e.g., morphine 5 mg peaks in 30 minutes, cutting pain (e.g., 8/10 to 3/10), unlike 'irrigate' , second e.g., after comfort. 'Loosen tape' follows e.g., reduces pull, not pain itself. 'Observe' assesses e.g., later step. A nurse plans e.g., Meds at 0900, change at 0930' ensuring comfort (e.g., 80% report less distress), a basic care priority. Potter stresses preemptive pain control, making the correct, initial intervention.
Question 4 of 5
Which assessment charting indicates that the wound is healing by primary intention?
Correct Answer: A
Rationale: The 4-inch incision edges are well approximated with intact sutures' shows primary intention, per Potter's *Essentials*. Clean closure e.g., sutured within 6 hours heals fast e.g., 7 days unlike 'ulcer with slough' , secondary e.g., open, slow. 'Deep incision with granulation' is secondary e.g., fills in. 'Abrasion' is superficial e.g., not sutured. A nurse charts e.g., Edges tight' primary's 80% rate, per surgical norms, a physiological marker. Potter contrasts with secondary's gap, making the correct, primary sign.
Question 5 of 5
The nurse is caring for a patient with a Stage IV pressure ulcer. Which type of healing will the nurse consider when planning care for this patient?
Correct Answer: B
Rationale: A Stage IV ulcer requires 'full-thickness wound repair'. Deep loss e.g., bone exposed heals via scar e.g., 4 phases: hemostasis to maturation unlike 'partial-thickness' , epidermal e.g., Stage II. 'Primary intention' is surgical e.g., closed fast. 'Tertiary intention' delays closure e.g., not typical. A nurse plans e.g., Debride, pack' per 20% Stage IV rate, a physiological focus. The text ties Stage IV to full repair, making the correct, deep healing type.