ATI LPN
NCLEX Questions Skin Integrity and Wound Care Questions
Question 1 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 2 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 3 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.
Question 4 of 5
Which of the functions of the skin is defined as 'water, electrolytes, and nitrogenous wastes are excreted in small amounts of sweat'
Correct Answer: D
Rationale: Elimination,' as this function describes the skin's role in excreting water, electrolytes, and nitrogenous wastes through sweat. Sweat glands produce sweat, a mixture containing these substances, aiding in waste removal and electrolyte balance, albeit in small amounts compared to kidneys. 'Protection' refers to the skin's barrier against pathogens and injury, not excretion. 'Sensation' involves nerve endings detecting stimuli, unrelated to waste. 'Regulation' covers temperature control via sweating or vasoconstriction, but the question specifies excretion, not thermoregulation. Elimination uniquely fits, as it's a recognized skin function in physiology, crucial for nursing knowledge in fluid balance and patient assessment e.g., excessive sweating might signal electrolyte loss. This specificity distinguishes 'Elimination' as the precise answer, aligning with the skin's excretory role.
Question 5 of 5
Imagine you are an ER nurse. Mr. Griffin has a large wound from a knife accident. Doctors let it heal on its own for days, then suture it later. What kind of wound healing has occurred?
Correct Answer: B
Rationale: Delayed primary intention,' as it fits Mr. Griffin's case: a large wound left open initially to heal naturally (allowing granulation and infection control), then sutured later. This method delays primary closure until the wound bed is stable, common for contaminated or traumatic injuries. 'Primary intention' involves immediate suturing, not waiting days. 'Tertiary intention' implies prolonged openness with later closure after significant healing, often for deeper wounds, but the question suggests a shorter delay. 'B and C' is incorrect only one process applies here. In nursing, delayed primary intention balances infection risk and closure, critical for trauma care. The sequence of open healing then suturing pinpoints B as the accurate description.