ATI LPN
NCLEX Questions Skin Integrity and Wound Care Questions
Question 1 of 5
A hospital is implementing clinical decision support to detect potential drug-drug interactions during medication ordering. Which of the following will be most important to ensure effective implementation?
Correct Answer: C
Rationale: Effective CDS balances usability. Allowing overrides with reasons , per the test and CDS best practices, maintains workflow while ensuring accountability, avoiding frustration from hard stops. Limiting to trainees misses broad use. All statuses slow systems. Constant training burdens users. This fits real-time needs, making it the correct choice.
Question 2 of 5
The evening nurse reviews the nursing documentation in a client's chart and notes that the day nurse has documented that the client has a stage II pressure ulcer in the sacral area. Which finding would the nurse expect to note on assessment of the client's sacral area?
Correct Answer: D
Rationale: Stage II ulcers are partial. Partial-thickness loss , per NPUAP staging, shows blisters or shallow craters, matching documentation. Intact skin is stage 1. Full-thickness or exposed tissue are stages III-IV. The nurse expects dermis-level damage, guiding dressing choice, making this the correct finding.
Question 3 of 5
A client has a wound on the lower leg that is covered with dry, yellow crusts. The nurse recognizes this as an indication of:
Correct Answer: A
Rationale: Slough is the correct answer, as it refers to dead tissue that appears as dry, yellow crusts on a wound's surface, indicating tissue that needs removal to promote healing. Slough can vary in color (white, yellow, green, or brown) and texture (soft, moist, or dry), and its presence suggests the wound is not fully progressing toward recovery without intervention like debridement. Eschar is also dead tissue but is typically black, brown, or tan, with a hard, leathery texture, often serving as a natural barrier in some cases but potentially impeding healing in others. Granulation tissue is healthy, new tissue that appears red or pink, shiny, and moist, signaling active healing, not crusting. Epithelial tissue is the thin, smooth layer forming over granulation tissue in the final healing stages, not matching the dry, yellow description. The dry, yellow crusts clearly point to slough, distinguishing it from the other options based on appearance and role in wound progression.
Question 4 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 odor from the wound is the correct answer, as it suggests a potential complication like infection or necrotic tissue, which can impede healing and lead to serious issues like sepsis. Serous drainage is normal, consisting of clear, watery fluid from capillaries, and doesn't inherently signal trouble unless excessive or cloudy. Erythema around the wound edges is expected during healing, reflecting increased blood flow and inflammation, not necessarily a complication unless it worsens or spreads. Granulation tissue in the wound bed is a positive sign of healing, indicating new tissue growth, not a problem. Foul odor, however, often accompanies bacterial overgrowth or dead tissue breakdown, requiring immediate assessment, possibly a culture, and intervention to prevent escalation, distinguishing it as a red flag among these findings.
Question 5 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.