ATI LPN
Skin Integrity and Wound Care Questions Questions
Question 1 of 5
A client is admitted with a burn injury that involves the epidermis and part of the dermis. The nurse knows that this type of burn is classified as:
Correct Answer: B
Rationale: A burn involving the epidermis and part of the dermis is classified as a partial-thickness burn, making choice B the correct answer. This type of burn typically presents with blisters, significant pain due to exposed nerve endings, and redness as blood vessels in the dermis are affected. It may heal spontaneously within two to three weeks with proper care or require skin grafting if deeper layers are involved. Superficial burns only affect the epidermis, causing mild pain and erythema without blisters, and heal quickly within days without scarring. Full-thickness burns extend through the epidermis, dermis, and into underlying tissues like fat or muscle, resulting in a charred appearance, no pain due to nerve destruction, and the need for surgical intervention. Deep partial-thickness burns involve most of the dermis, presenting with white or red skin and severe pain, often requiring grafting due to slower healing. The distinction lies in the depth of tissue involvement, and partial-thickness best matches the description provided.
Question 2 of 5
A client with diabetes mellitus has a diabetic foot ulcer on the left heel. The nurse is preparing to apply a hydrocolloid dressing to the wound. What is an advantage of using this type of dressing?
Correct Answer: D
Rationale: as hydrocolloid dressings stimulate autolytic debridement of necrotic tissue, a key advantage for a diabetic foot ulcer. These dressings are occlusive, forming a gel-like layer over the wound that traps moisture and enzymes, naturally breaking down dead tissue without mechanical intervention. This process is gentle, reducing trauma to surrounding healthy tissue, which is crucial for diabetic patients prone to slow healing. While providing a moist environment is true, it's not unique to hydrocolloids other dressings like hydrogels also do this making it less specific. Absorbing large amounts of exudate is incorrect, as hydrocolloids handle only minimal to moderate drainage, unlike alginates, and can leak if overwhelmed. Allowing frequent inspection is false; hydrocolloids are opaque and typically left in place for days, not designed for regular viewing. Autolytic debridement stands out as the distinct benefit, supporting healing in chronic wounds like diabetic ulcers by clearing necrotic debris efficiently.
Question 3 of 5
A client is receiving negative pressure wound therapy (NPWT) for a chronic wound on the lower leg. The nurse observes that the wound edges are approximated and granulation tissue is filling the wound bed. Which action should the nurse take?
Correct Answer: C
Rationale: Discontinuing NPWT and applying a moist dressing is the correct action when wound edges are approximated and granulation tissue fills the bed. This indicates successful healing progression, as NPWT has achieved its goals removing fluid, reducing edema, and stimulating tissue growth. Continuing beyond this point risks overgranulation or maceration, while a moist dressing supports epithelialization in the final stages. Increasing dressing changes disrupts healing and isn't warranted with good progress. Decreasing pressure reduces efficacy unnecessarily, as the therapy's work is largely done. Continuing until complete closure may over-treat, causing complications like tissue overgrowth. Transitioning to a moist dressing aligns with wound healing phases, shifting from granulation support to surface closure, reflecting evidence-based practice for chronic wound management.
Question 4 of 5
A client with arterial insufficiency has an arterial ulcer on the dorsum of the foot. Which assessment finding should alert the nurse to a potential complication?
Correct Answer: D
Rationale: Gangrene or necrosis of the toes is the correct finding to alert the nurse to a potential complication in an arterial ulcer. Arterial insufficiency reduces blood supply, causing ischemia, and gangrene dead tissue from prolonged oxygen deprivation signals severe progression, risking amputation or infection if not addressed urgently. Absent or diminished pedal pulses are expected in arterial insufficiency, reflecting chronic poor perfusion, not an acute complication unless suddenly worsening. Cold, pale, or cyanotic skin is typical due to low oxygen delivery, a baseline sign rather than an immediate threat. Loss of hair growth results from chronic nutrient deficiency, not an emergent issue. Gangrene escalates the situation, indicating critical tissue loss beyond typical arterial ulcer symptoms, necessitating immediate provider notification for intervention.
Question 5 of 5
A nurse is caring for a client who has a stage 3 pressure ulcer on the sacrum. Which type of dressing should the nurse use to promote moist wound healing?
Correct Answer: A
Rationale: Hydrocolloid is the correct dressing to promote moist wound healing in a stage 3 pressure ulcer. Its occlusive, adhesive nature forms a gel over the wound, retaining moisture, facilitating autolytic debridement, and protecting from contamination ideal for deeper wounds with moderate drainage. Transparent film allows oxygen exchange but doesn't absorb exudate or cushion, better for stage 1 ulcers. Calcium alginate is highly absorbent for heavy drainage, more suited to stage 4 ulcers, and less focused on moisture retention alone. Gauze can stick and dry out, disrupting healing and causing trauma. Hydrocolloid's moisture-maintaining properties support granulation and epithelialization in a stage 3 ulcer, reducing pain and enhancing recovery, making it the optimal choice.