ATI RN
NCLEX Skin Integrity Questions Questions
Question 1 of 5
A nurse documents a closed wound on a patient chart. Which of the following is an example of a closed wound?
Correct Answer: B
Rationale: Ecchymosis' is a closed wound. Bruising e.g., 3 cm purple keeps skin intact e.g., blood beneath unlike 'abrasion' , scraped e.g., open. 'Incision' cuts e.g., surgical, open. 'Puncture' pierces e.g., 1 mm deep, open. A nurse charts e.g., Bruise, no break' per 80% closed type, a physiological call. The text defines closed as unbroken, making the correct, intact example.
Question 2 of 5
Of the many topics that may be taught to patients or caregivers about home wound care, which one is the most significant in preventing wound infections?
Correct Answer: C
Rationale: Thorough hand hygiene' prevents infections most. Hands e.g., 10 bacteria spread 90% risk unlike 'medications' , treatment e.g., not prevention. 'Food, fluids' heals indirect. 'Sleep' supports e.g., not primary. A nurse teaches e.g., Wash first' per 80% reduction, a physiological must. The text prioritizes hygiene, making the correct, top topic.
Question 3 of 5
Aaron is wearing anti-embolic stockings (TED hose) how should the nurse assess these areas wearing the TED hose?
Correct Answer: B
Rationale: Correct Answer: B - Assess after removing the hose. Rationale: The nurse should assess the skin after removing the TED hose to thoroughly examine for any signs of skin irritation, pressure injury, or discoloration. Assessing over the hose (A) may not provide a complete view of the skin condition. Rolling down the hose (C) or rolling up the hose (D) can cause friction and compromise the integrity of the skin, making it an incorrect method for assessment.
Question 4 of 5
Which protective equipment will the nurse use when providing the prescribed wound care for MRSA?
Correct Answer: D
Rationale: The correct answer is D because MRSA is a highly contagious bacterium that can be transmitted through contact with infected wounds or secretions. Gloves are necessary to protect against direct contact, a gown adds an extra layer of protection for clothing contamination, goggles protect the eyes from splashes, and a face mask prevents inhalation of MRSA particles. Using only gloves (A) is insufficient protection. Adding a gown (B) is better but does not protect the face and eyes. Adding goggles (C) provides protection for the eyes but not the face. The most comprehensive protection is achieved with gloves, gown, goggles, and a face mask (D).
Question 5 of 5
Which actions should the nurse take to help the client with bowel and bladder dysfunction reduce the risk of infection? Select the one that does not apply
Correct Answer: A
Rationale: The correct answer is A: Isolate the client using transmission-based precautions. This is incorrect because bowel and bladder dysfunction does not typically require isolation measures unless there is a specific infectious disease present. B: Monitoring intake and output is important to assess kidney function and fluid balance in clients with bowel and bladder dysfunction. C: Providing hygienic care after episodes of incontinence helps prevent skin breakdown and infections. D: Using standard precautions when handling linen after episodes of incontinence is necessary to prevent the spread of infections to healthcare workers and other clients.