ATI LPN
NCLEX Style Questions on Skin Integrity and Wound Care Questions
Question 1 of 5
A nurse assesses a burn injury and determines that the client sustained a fullthickness fourth-degree burn if which of the following is noted at the site of injury?
Correct Answer: C
Rationale: Fourth-degree burns extend beyond the skin into underlying tissues (muscle, bone), often resulting in charring due to severe destruction.
Question 2 of 5
A nurse is performing a skin assessment of a client who is immobile and notes the presence of partial thickness skin loss of the upper layer of the skin in the sacral area. The nurse documents these findings as a:
Correct Answer: B
Rationale: Stage 2 pressure ulcers involve partial-thickness loss of the epidermis and/or dermis, as described.
Question 3 of 5
While waiting to see the physician, a patient shows the nurse skin areas that are flat, nonpalpable, and have had a change of color. The nurse recognizes that the patient is demonstrating what?
Correct Answer: A
Rationale: A macule is a flat, nonpalpable skin color change, while a papule is an elevated, solid, palpable mass. A vesicle is a circumscribed, elevated, palpable mass containing serous fluid, while a pustule is a pus-filled vesicle.
Question 4 of 5
The nurse is performing an initial assessment of a patient who has a raised, pruritic rash. The patient denies taking any prescription medication and denies any allergies. What would be an appropriate question to ask this patient at this time?
Correct Answer: C
Rationale: If suspicious areas are noted, the patient is questioned about nonprescription or herbal preparations that might be in use.
Question 5 of 5
When paramedics notice singed hairs in the nose of a burn patient, it is recommended that the patient be intubated. What is the reasoning for the immediate intubation?
Correct Answer: B
Rationale: In inhalation injury, the airway may become edematous quickly, making intubation difficult. Early intubation is recommended to protect the airway. Carbon monoxide poisoning may be present, but singed nose hairs are neither a symptom nor a reason for early intubation. Management of secretions is not an indication for intubation. Singed hairs and soot are more commonly symptoms of injury above the glottis rather than lower airway, below-the-glottis, signs and symptoms that will interfere with oxygenation and ventilation.