ATI LPN
NCLEX Style Questions on Skin Integrity and Wound Care Questions
Question 1 of 5
A 75-year-old patient questions the nurse about vaccination to prevent shingles. Which response is most appropriate?
Correct Answer: C
Rationale: The vaccination should be considered by high-risk populations. About 50% of individuals over age 80 years will have the disease. The vaccination has been approved for use. The immunity provided is anticipated to last for 6 years.
Question 2 of 5
A nurse is assessing the operative site in a client who underwent a breast reconstruction. The nurse is inspecting the flap and the areola of the nipple and notes that the areola is a deep red color around the edge. The nurse takes which action first?
Correct Answer: D
Rationale: Deep red color may indicate vascular compromise or infection, requiring immediate physician evaluation.
Question 3 of 5
A nurse is performing a skin assessment of a client who is immobile and notes the presence of partial thickness skin loss of the upper layer of the skin in the sacral area. The nurse documents these findings as a:
Correct Answer: B
Rationale: Stage 2 pressure ulcers involve partial-thickness loss of the epidermis and/or dermis, as described.
Question 4 of 5
While waiting to see the physician, a patient shows the nurse skin areas that are flat, nonpalpable, and have had a change of color. The nurse recognizes that the patient is demonstrating what?
Correct Answer: A
Rationale: A macule is a flat, nonpalpable skin color change, while a papule is an elevated, solid, palpable mass. A vesicle is a circumscribed, elevated, palpable mass containing serous fluid, while a pustule is a pus-filled vesicle.
Question 5 of 5
The nurse is performing an initial assessment of a patient who has a raised, pruritic rash. The patient denies taking any prescription medication and denies any allergies. What would be an appropriate question to ask this patient at this time?
Correct Answer: C
Rationale: If suspicious areas are noted, the patient is questioned about nonprescription or herbal preparations that might be in use.