ATI LPN
Skin Integrity NCLEX Questions Questions
Question 1 of 5
A client has a wound with a moderate amount of drainage and is scheduled for a dressing change. Which dressing, if selected by the student nurse, requires further intervention by the nursing instructor?
Correct Answer: D
Rationale: Drainage needs absorption. Semipermeable film , per wound care guidelines, suits minimal exudate, not moderate, risking leakage and infection. Foam and alginate absorb well. Hydrocolloid manages light-to-moderate but seals less effectively here. The instructor intervenes to ensure proper exudate management, critical for healing, making this the dressing needing correction.
Question 2 of 5
A client has a venous ulcer on the lower leg that is treated with compression therapy. The nurse instructs the client to elevate the leg above the level of the heart whenever possible. What is the rationale for this instruction?
Correct Answer: A
Rationale: Choice A is correct because elevating the leg above the heart reduces edema and venous pressure, which is the primary rationale for this instruction in managing a venous ulcer. Venous ulcers stem from chronic venous insufficiency, causing blood pooling, increased pressure, and swelling in the lower legs. Elevation leverages gravity to enhance venous return to the heart, alleviating these issues and supporting healing. Increasing arterial blood flow and oxygenation is more relevant to arterial ulcers, where elevation might worsen perfusion by countering gravity's aid to arterial flow. Preventing infection and inflammation is critical but not directly tied to elevation; it relies more on wound care practices like cleansing and dressings. Stimulating nerve regeneration and sensation is unrelated to venous ulcers or elevation, as neuropathy isn't a primary concern here. Thus, reducing edema and venous pressure best explains the benefit of elevation in this context.
Question 3 of 5
A nurse is assessing a client with a pressure ulcer on the sacrum. Which finding indicates a potential complication of the wound?
Correct Answer: C
Rationale: Foul-smelling greenish discharge is the correct answer, indicating a potential complication such as infection in the pressure ulcer. This type of discharge, often linked to bacteria like Pseudomonas, combined with a foul odor, suggests microbial overgrowth that can hinder healing and lead to serious outcomes like sepsis if untreated. Prompt reporting and a wound culture are critical to identify the pathogen and tailor treatment. Serous drainage is typically clear and watery, a normal part of healing unless it becomes excessive or purulent. Redness and warmth around the wound are expected signs of inflammation and increased blood flow during early healing stages, not necessarily problematic unless accompanied by worsening symptoms. Granulation tissue is a healthy sign, showing new tissue growth and vascularization, not a complication. The distinct foul-smelling, greenish discharge stands out as an abnormal finding requiring immediate attention, distinguishing it from the other options.
Question 4 of 5
A nurse is preparing to change a dressing on a client's surgical incision. Which type of dressing should the nurse use to promote autolytic debridement of the wound?
Correct Answer: D
Rationale: Hydrogel dressing is the correct answer to promote autolytic debridement in a surgical incision. Autolytic debridement uses the body's enzymes and moisture to break down necrotic tissue, and hydrogel, being water- or glycerin-based, hydrates the wound, creating an ideal moist environment for this process. This is gentle and effective for incisions with minor necrosis or slough, preserving healthy tissue. Alginate dressing is absorbent and suited for heavy exudate, not dry or minimally draining wounds needing debridement. Foam dressing cushions and absorbs moderate exudate but doesn't hydrate enough for autolysis. Gauze dressing can dry out and stick, causing trauma upon removal, and lacks the moisture retention needed for autolytic action. Hydrogel's ability to donate moisture distinguishes it, supporting natural debridement while minimizing pain and disruption, making it the best choice for this healing mechanism.
Question 5 of 5
A client with venous insufficiency has a venous stasis ulcer on the lower leg. Which instruction should the nurse give to the client to promote wound healing?
Correct Answer: D
Rationale: All of the above,' is correct, as all listed instructions applying compression stockings or bandages , avoiding crossing legs or tight clothing , and keeping the leg elevated promote healing of a venous stasis ulcer. Venous insufficiency causes blood pooling, edema, and pressure, impairing wound recovery. Compression therapy enhances venous return, reducing swelling and supporting circulation. Avoiding leg crossing or tight garments prevents vessel constriction, maintaining blood flow. Elevation above heart level uses gravity to drain fluid, alleviating edema and pressure. Each action targets a facet of venous ulcer pathology, and together, they form a comprehensive strategy to improve oxygenation, reduce inflammation, and accelerate healing, making D the most inclusive and effective choice for patient education in this chronic condition.