ATI RN
NCLEX Questions on Skin Integrity and Wound Care Questions
Question 1 of 5
A 79-year-old client has been confined to bed after a severe hemorrhagic stroke that has caused hemiplegia. Which of the following measures should his care team prioritize in the prevention of pressure ulcers?
Correct Answer: B
Rationale: The correct answer is B: Repositioning the client on a scheduled basis. This is crucial in preventing pressure ulcers in immobile patients by relieving pressure on vulnerable areas. Repositioning helps to improve blood flow, reduce tissue damage, and prevent skin breakdown. Prophylactic antibiotics (Choice A) are not indicated for pressure ulcer prevention. Applying protective dressings (Choice C) may offer some protection but does not address the root cause of pressure ulcers. Parenteral nutrition (Choice D) is important for providing essential nutrients but is not directly related to preventing pressure ulcers. In summary, regular repositioning is the most effective measure in preventing pressure ulcers in immobile patients.
Question 2 of 5
The patient has a large red, blistered area on the left hip. Which pressure injury stage will be recorded in the patient's chart?
Correct Answer: B
Rationale: A red, blistered hip area is 'Stage 2' , per Potter's *Essentials*. Partial-thickness loss e.g., ruptured blister 3 cm wide shows dermis, unlike 'Stage 1' , intact redness e.g., no break. 'Stage 3' is full-thickness e.g., fat, not blister. 'Stage 4' exposes bone e.g., deeper than skin. A nurse charts e.g., Blister open, pink' Stage 2's 40% incidence, per NPUAP, needing nonadherent dressing. Potter defines Stage 2 as shallow with no slough, distinct from Stage 3's depth, a physiological integrity marker. is the correct, dermal stage.
Question 3 of 5
Which is the priority nursing assessment for a patient wearing an abdominal binder after abdominal surgery?
Correct Answer: C
Rationale: For an abdominal binder post-surgery, 'lung sounds and pulse oximetry' are priority, per Potter's *Essentials*. Binders support incisions e.g., 10 cm long but tight fit risks breathing e.g., SpO2 drops 5% unlike 'mental status' , unaffected e.g., no brain link. 'Fluids' track hydration e.g., not binder-related. 'Pedal pulses' check circulation e.g., legs, not abdomen. A nurse listens e.g., Clear, 95%' ensuring ventilation (e.g., 80% of binder risks), a physiological integrity must. Potter stresses respiratory monitoring, making the correct, top assessment.
Question 4 of 5
Which priority element will the nurse consider when planning care to decrease the development of a decubitus ulcer for a patient who sustained a head injury and is unconscious?
Correct Answer: B
Rationale: Pressure' is the priority to reduce decubitus ulcers in an unconscious patient. Pressure intensity e.g., >32 mmHg duration e.g., 2 hours and tissue tolerance cause ischemia e.g., sacral redness unlike 'resistance' , vague e.g., not a factor. 'Weight' contributes e.g., bony pressure but isn't primary. 'Stress' is emotional e.g., not mechanical. A nurse plans e.g., Turn q2h' cutting 60% of risk, per studies, a physiological focus. The text emphasizes pressure's role over secondary elements, making the correct, critical element.
Question 5 of 5
The nurse is caring for a patient in the burn unit. Which type of wound healing will the nurse consider when planning care for this patient?
Correct Answer: B
Rationale: Burns heal by 'secondary intention'. Tissue loss e.g., 3rd-degree fills with scar e.g., weeks unlike 'partial-thickness' , epidermal e.g., minor burns. 'Tertiary intention' delays e.g., not typical. 'Primary intention' is closed e.g., surgery. A nurse plans e.g., Moist dressings' per 60% burn cases, a physiological need. The text notes secondary's slow, infection-prone path, making the correct, open healing type.