ATI LPN
NCLEX Practice Questions Skin Integrity and Wound Care Questions
Question 1 of 5
A client arriving at the emergency department has experienced frostbite to the right hand. Which finding would the nurse note on assessment of the client's hand?
Correct Answer: D
Rationale: Frostbite shows tissue freezing. White, insensitive skin , per emergency nursing texts, indicates early frostbite (stage 1), with vasoconstriction and numbness. Pink edema suggests rewarming. Red skin or black tips reflect later stages (thawing or necrosis). Initial assessment notes pallor and sensory loss, guiding rewarming care, making this the correct finding.
Question 2 of 5
A client with a surgical wound on the abdomen has a negative pressure wound therapy (NPWT) device attached to the wound. Which action should the nurse take when caring for this client?
Correct Answer: C
Rationale: Choice C is correct because ensuring the dressing is sealed and airtight around the wound is essential for effective negative pressure wound therapy (NPWT). NPWT relies on consistent subatmospheric pressure to promote healing by removing fluid, reducing edema, and stimulating granulation tissue, which requires an airtight seal to maintain suction. Changing the dressing every 12 hours is too frequent; NPWT dressings are typically changed every 48-72 hours unless specified otherwise, as frequent changes disrupt healing. Irrigating with saline before dressing risks introducing bacteria and interrupting pressure, countering NPWT's purpose cleaning should occur prior, not during application. Clamping the tubing during movement disrupts pressure and risks tissue damage; securing it to avoid kinking is preferred. An airtight seal ensures NPWT's therapeutic benefits, making it the priority action.
Question 3 of 5
A nurse is caring for a client who has undergone a skin graft to cover a burn injury on the right arm. Which intervention should the nurse include in the plan of care to promote graft adherence?
Correct Answer: C
Rationale: Immobilizing the right arm with a splint or sling is the correct answer, as it promotes graft adherence by preventing movement and shear forces that could dislodge the newly placed skin graft. Stability is critical in the initial days post-grafting to allow the graft to establish blood supply from the wound bed, ensuring survival and integration. Elevation may reduce edema but isn't the primary intervention for adherence, though it can aid comfort and swelling control. Applying negative pressure wound therapy is contraindicated for grafts, as suction could disrupt fragile tissue, cause bleeding, or lift the graft, undermining its purpose. Irrigation with saline twice daily risks disturbing the graft's attachment and introduces infection risk, countering sterile post-op protocols that favor minimal interference. Immobilization directly addresses the mechanical stability needed for graft take, making it the most effective nursing action in this scenario, supported by standard wound care principles.
Question 4 of 5
A nurse is assessing a client who has a pressure ulcer on the sacrum. Which finding should the nurse report to the wound care specialist?
Correct Answer: B
Rationale: Yellowish-green drainage is the correct finding to report to the wound care specialist, as it strongly suggests infection or necrosis in the pressure ulcer. This purulent exudate, often tied to bacterial presence like Pseudomonas or Staphylococcus, requires urgent evaluation, possibly a culture, and treatment to prevent worsening or systemic spread. Foul odor may hint at infection or anaerobic bacteria but isn't definitive alone, as some wounds smell without being infected, making it less specific. Granulation tissue is a positive healing sign, not a concern, indicating new tissue formation. Partial-thickness skin loss aligns with pressure ulcer staging (e.g., Stage 2) and isn't an acute issue to report unless deteriorating. The yellowish-green drainage stands out as a critical, actionable finding, necessitating specialist input to address potential infection and optimize care.
Question 5 of 5
A nurse is assessing a client who has a pressure ulcer on the sacrum. Which finding indicates a possible infection of the wound?
Correct Answer: C
Rationale: Increased pain and tenderness is the correct answer, indicating a possible infection in the pressure ulcer. Infection triggers an inflammatory response, heightening nerve sensitivity and causing more pain and tenderness, a shift from baseline that warrants a culture and provider input. Serous drainage is normal clear and watery unless it turns cloudy or purulent, which isn't specified here. Reddened periwound skin reflects healing-related blood flow, not infection, unless spreading or hot. Granulation tissue signifies healthy repair, not infection, unless it's pale or deteriorating. Pain and tenderness stand out as infection markers, as bacteria amplify inflammation, distinguishing this finding in a wound assessment and signaling a need for further investigation.