ATI LPN
Skin Integrity and Wound Care Questions Questions
Question 1 of 5
A long-term care nurse cares for an older male who is withdrawn, quiet, and grimaces when touched. The most appropriate action is:
Correct Answer: B
Rationale: Grimacing and withdrawal suggest pain. Assessing causes e.g., arthritis guides care, per nursing process. Meds need basis. Repositioning delays. Notification follows assessment. Thorough evaluation ensures targeted relief, an LPN duty, making it the correct action.
Question 2 of 5
Which nursing observation will indicate the wound healed by secondary intention?
Correct Answer: D
Rationale: Secondary intention, for wounds like burns, leaves severe scarring (Choice D), per the text, as open wounds fill with scar tissue, potentially impairing function. Minimal tissue loss and minimal scarring suit primary intention. Dark redness isn't typical. Severe scarring reflects the healing process's extent, a key observation nurses document, making this the correct indicator of secondary intention healing.
Question 3 of 5
Which nutrient will the nurse most likely increase after collaboration with the dietitian for a patient with a Stage III pressure ulcer?
Correct Answer: B
Rationale: Protein is critical for wound healing, per the text, supporting collagen synthesis and tissue repair in Stage III ulcers. Fats and carbohydrates provide energy but aren't primary. Vitamin E isn't emphasized. Nurses and dietitians boost protein (e.g., 1.25-1.5 g/kg/day) to heal deep wounds, making this the correct nutrient to increase.
Question 4 of 5
Which next step will the nurse anticipate for a pressure ulcer that is black?
Correct Answer: C
Rationale: Black tissue is necrotic, requiring debridement (Choice C), per the text, to remove infection sources and promote healing. Monitoring delays care. Documentation follows action. Drainage isn't primary. Debridement clears the wound bed, making this the correct anticipated step.
Question 5 of 5
Which nursing diagnosis will the nurse assign to a patient with a reddened, nonblanchable area on the right heel?
Correct Answer: B
Rationale: Nonblanchable redness signals impaired blood flow, fitting 'Ineffective peripheral tissue perfusion' (Choice B), per the text, as oxygen delivery falters. Nutrition isn't indicated. Infection and pain may follow but aren't primary. This diagnosis targets circulation, making it the correct assignment.