ATI LPN
Skin Integrity and Wound Care Questions Questions
Question 1 of 5
A client with a burn wound on the chest has a silver sulfadiazine (Silvadene) cream applied to the wound. Which adverse reaction should the nurse monitor for in this client?
Correct Answer: D
Rationale: as the nurse should monitor for both hypersensitivity or allergic reaction and leukopenia or decreased white blood cell count when using silver sulfadiazine (Silvadene) on a burn wound. This topical antimicrobial can cause allergic reactions like rash, itching, or swelling, which may escalate to severe symptoms like difficulty breathing, requiring immediate attention. It can also lead to leukopenia, a drop in white blood cells, increasing infection risk, necessitating regular blood count monitoring. Hyperglycemia isn't a typical adverse reaction to Silvadene; it may occur in burn patients due to stress or infection, not the cream itself. Since both A and B are valid concerns supported by the need for baseline and periodic complete blood counts choice D encompasses the full scope of critical monitoring, ensuring comprehensive care for potential complications.
Question 2 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 3 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 4 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.
Question 5 of 5
The skin has __ layers, in addition to the subcutaneous tissue layer
Correct Answer: B
Rationale: Two,' because the skin comprises two primary layers the epidermis and dermis excluding the subcutaneous tissue layer, which is beneath the skin proper. The epidermis, the outermost layer, acts as a waterproof barrier and protects against pathogens, while the dermis, below it, houses blood vessels, nerves, and glands, providing strength and elasticity. The subcutaneous layer, or hypodermis, is a separate entity of fat and connective tissue, not counted as a skin layer but as underlying support. 'One' is incorrect, as it ignores the dermis. 'Three' might confuse the subcutaneous layer as a skin layer, which it isn't in standard terminology. 'Four' exceeds the anatomical structure entirely. This distinction is vital in nursing for assessing skin integrity and wounds, as each layer's condition affects healing and care strategies, making 'Two' the accurate choice based on established skin anatomy.