ATI LPN
NCLEX Questions Skin Integrity and Wound Care Questions
Question 1 of 5
A client has a wound on the lower leg that is covered with dry, yellow crusts. The nurse recognizes this as an indication of:
Correct Answer: A
Rationale: Slough is the correct answer, as it refers to dead tissue that appears as dry, yellow crusts on a wound's surface, indicating tissue that needs removal to promote healing. Slough can vary in color (white, yellow, green, or brown) and texture (soft, moist, or dry), and its presence suggests the wound is not fully progressing toward recovery without intervention like debridement. Eschar is also dead tissue but is typically black, brown, or tan, with a hard, leathery texture, often serving as a natural barrier in some cases but potentially impeding healing in others. Granulation tissue is healthy, new tissue that appears red or pink, shiny, and moist, signaling active healing, not crusting. Epithelial tissue is the thin, smooth layer forming over granulation tissue in the final healing stages, not matching the dry, yellow description. The dry, yellow crusts clearly point to slough, distinguishing it from the other options based on appearance and role in wound progression.
Question 2 of 5
A client has an arterial ulcer on the left lower leg. The nurse observes that the ulcer has a pale pink base, minimal drainage, and no signs of infection. What is an appropriate dressing for this ulcer?
Correct Answer: D
Rationale: Hydrogel dressing is the correct answer for an arterial ulcer with a pale pink base, minimal drainage, and no infection. Arterial ulcers, caused by poor blood flow, often present as dry or minimally exudative wounds, and hydrogel provides essential moisture to rehydrate the wound bed, promoting autolytic debridement and healing. Its water- or glycerin-based composition suits this scenario, preventing desiccation while supporting tissue regeneration. Transparent film offers protection but lacks moisture donation, making it better for superficial, dry wounds, not arterial ulcers needing hydration. Calcium alginate is highly absorbent, ideal for heavy exudate, not minimal drainage, and could dry out this wound further. Silver-impregnated dressing targets infection, unnecessary here without signs of bacterial involvement. Hydrogel's hydrating properties align perfectly with the ulcer's characteristics, fostering an optimal healing environment without overwhelming the wound or surrounding skin.
Question 3 of 5
A client is receiving negative pressure wound therapy (NPWT) for a diabetic foot ulcer. Which action should the nurse take when changing the dressing?
Correct Answer: A
Rationale: Applying sterile saline to moisten the foam dressing before removal is the correct action during an NPWT dressing change for a diabetic foot ulcer. The foam can adhere to the wound bed, and moistening it with saline prevents trauma, pain, or bleeding upon removal, protecting fragile granulation tissue common in diabetic wounds. Cutting the foam loosely is incorrect; it should fit snugly to ensure even pressure distribution. Securing the film with tape risks air leaks; an adhesive drape extending beyond the edges is standard to maintain the seal. Disconnecting tubing from the foam first disrupts suction prematurely; it should detach from the device first to avoid pressure issues. Moistening with saline is a precise, evidence-based step to safeguard the wound, especially critical in diabetic patients with impaired healing.
Question 4 of 5
A client is admitted to the hospital with a diabetic foot ulcer. The nurse notes that the wound has black, dry, and hard tissue covering most of the wound bed. How should the nurse document this finding?
Correct Answer: A
Rationale: Eschar is the correct documentation for black, dry, and hard tissue covering a diabetic foot ulcer's wound bed. Eschar is necrotic tissue that's firm and adherent, often stable (dry, intact) or unstable (moist, loose), and in diabetic wounds, it delays healing and risks infection, requiring accurate identification. Slough is softer, moist, and typically yellow or green, not matching the dry, hard description. Fibrin is a yellowish clotting protein, not black or extensive like eschar. Exudate is fluid, not tissue, and doesn't fit. Eschar's distinct characteristics color, texture, and dryness differentiate it, and proper documentation guides treatment, like debridement, critical for diabetic wound management to prevent complications like osteomyelitis.
Question 5 of 5
A nurse is preparing to change a wet-to-dry dressing for a client who has a chronic wound on the lower leg. Which action by the nurse demonstrates proper technique?
Correct Answer: C
Rationale: Moistening the new dressing with sterile water, wringing it out, and applying it is the correct technique for a wet-to-dry dressing. This method mechanically debrides necrotic tissue as the dressing dries and adheres, lifting debris upon removal. Sterile water is preferred over saline to avoid sodium crystal formation, and wringing prevents maceration while ensuring contact with the wound bed. Soaking the old dressing reduces debridement by softening adhered tissue. Antibiotic ointment interferes with adhesion and risks resistance, countering the dressing's purpose. An occlusive cover traps moisture, promoting infection rather than drying for debridement. Proper technique with moistening and wringing balances efficacy and safety, optimizing chronic wound care.