ATI RN
Skin Integrity and Wound Care NCLEX Questions Questions
Question 1 of 5
A client has just received the diagnosis of malignant melanoma, stage 3B. He asks the nurse what this means. The nurse should respond relaying which of the following information? Select all that apply.
Correct Answer: A
Rationale: The correct answer is A because malignant melanoma is indeed a very rapid growing and aggressive cancer. This information is crucial for the client to understand the seriousness of the diagnosis and the need for prompt and aggressive treatment. Explanation of why other choices are incorrect: B: This cancer usually extends wide and deep but rarely metastasize - This statement is incorrect because malignant melanoma is known to have a high potential for metastasis. C: This cancer is mainly contained to the head and neck area - This statement is incorrect because melanoma can occur on any part of the body, not just limited to the head and neck. D: Your cancer has grown into the deep tissues and quite likely into lymph nodes (stage 3B) - While this choice provides some accurate information about the staging of the cancer, it does not fully address the client's question about the nature of malignant melanoma.
Question 2 of 5
The nurse is caring for a patient with a puncture wound. How much time must have passed since the patient's last tetanus toxoid vaccination for the patient to require an additional injection before being discharged from the emergency department?
Correct Answer: D
Rationale: For a dirty puncture wound, '10 years' since last tetanus toxoid triggers a booster, per Potter's *Essentials*. CDC guidelines mandate e.g., after 10 years, immunity wanes (e.g., 50% antibody drop) unlike '1 year' , too soon e.g., still protective. '3 years' and '5 years' apply to cleaner wounds e.g., not this risk. A nurse asks e.g., Last shot 2012?' if over 10 (e.g., 2025 now), injects, reducing tetanus odds (e.g., 1/1000 to near zero). Potter stresses this for dirty trauma, a health promotion must. is the correct, evidence-based cutoff.
Question 3 of 5
How will the nurse obtain a culture of the patient's wound?
Correct Answer: D
Rationale: To culture a wound, 'gently swab the center after irrigating with sterile saline' is correct, per Potter's *Essentials*. Irrigation e.g., 10 mL saline cleans debris, ensuring accurate swab e.g., 90% pathogen catch unlike 'drainage bag' , contaminated e.g., old fluid. 'Edge' misses e.g., surface bacteria, not core. 'Dressing' taints e.g., external bugs. A nurse swabs e.g., Clean center' per infection control (e.g., CLSI standards), a safety must. Potter stresses sterile technique, making the correct, precise method.
Question 4 of 5
The wound care nurse visits a patient in the long-term care unit. The nurse is monitoring a patient with a Stage III pressure ulcer. The wound seems to be healing, and healthy tissue is observed. How should the nurse document this ulcer in the patient's medical record?
Correct Answer: C
Rationale: A healing Stage III ulcer is documented as 'Healing Stage III pressure ulcer'. Stage III e.g., full-thickness, fat visible retains its label e.g., doesn't revert to 'Stage I' , intact redness. 'Healing Stage II' is partial e.g., not this depth. 'Stage III' omits progress e.g., granulation seen. A nurse writes e.g., Healing Stage III, pink tissue' per NPUAP, noting 80% heal thus, a physiological marker. The text mandates healing' addition, making the correct, accurate entry.
Question 5 of 5
The nurse is caring for a patient who has experienced a total abdominal hysterectomy. Which nursing observation of the incision will indicate the patient is experiencing a complication of wound healing?
Correct Answer: D
Rationale: A 'bluish mass' signals a hematoma, a healing complication. Blood under tissue e.g., 50 mL shows swelling e.g., 2 cm unlike 'hurting' , normal e.g., nerve trauma. 'Approximated' is healing e.g., edges shut. 'Itching' is progress e.g., regeneration. A nurse notes e.g., Blue lump' per 10% post-op risk, needing monitoring. The text flags hematoma's vascular threat, making the correct, alarming observation.