ATI LPN
Skin Integrity and Wound Care NCLEX Questions Questions
Question 1 of 5
A nurse is admitting a client to the unit. Which cultural question is most appropriate?
Correct Answer: A
Rationale: Culturally respectful care seeks client input. Asking about dietary needs and preferences aligns with transcultural nursing (e.g., Leininger's model), capturing specifics like kosher or halal diets, fostering trust. Choice B assumes standard food fits, ignoring culture. Choice C is narrow, missing preferences. Choice D is incomplete and unclear due to OCR error, likely irrelevant. Per nursing standards, open-ended questions ensure individualized care, respecting beliefs (e.g., fasting practices), making this the most appropriate question.
Question 2 of 5
A client is recovering and the nurse would encourage the client to eat which food item that is naturally high in vitamin C to promote wound healing?
Correct Answer: B
Rationale: Vitamin C aids collagen. Oranges , per nutrition science, are high in vitamin C (~70mg/fruit), boosting wound repair. Milk offers protein, not C. Bananas provide potassium. Chicken supports protein, not C. Encouraging citrus enhances healing, per dietary guidelines, making this the correct food.
Question 3 of 5
A nurse is applying a dressing to a wound that has moderate to heavy exudate. Which of the following types of dressing would be most appropriate for this wound?
Correct Answer: D
Rationale: Alginate is the correct answer because it is highly absorbent, capable of managing moderate to heavy exudate by absorbing up to 20 times its weight in fluid, making it ideal for such wounds. It forms a gel when in contact with exudate, maintaining a moist environment that supports healing and autolytic debridement, while preventing maceration of surrounding skin. Transparent film is non-absorbent and suited for dry wounds, offering protection but not fluid management. Hydrogel is minimally absorbent and better for dry or minimally exudative wounds, providing hydration rather than absorption. Foam is moderately absorbent, handling light to moderate exudate, but less effective than alginate for heavy drainage due to its lower capacity (up to four times its weight). The wound's moderate to heavy exudate requires a dressing like alginate to effectively manage fluid and promote optimal healing conditions.
Question 4 of 5
A client is admitted to the hospital with a burn injury covering $30% of the body surface area. The nurse anticipates that the client will require which type of dressing for wound care?
Correct Answer: D
Rationale: Silver dressing is the correct answer because it's ideal for burn injuries covering 30% of the body surface area due to its antimicrobial properties, reducing infection risk a major concern in burns where skin barriers are compromised. Silver ions kill bacteria, manage pain, inflammation, and odor, supporting healing in high-risk wounds. Hydrocolloid dressing is occlusive, suited for minimal-drainage wounds, but can trap bacteria in infected or heavily exudative burns, risking maceration. Hydrogel dressing hydrates dry wounds but lacks sufficient absorption for burn exudate and isn't antimicrobial, making it less suitable. Alginate dressing absorbs heavy exudate but isn't ideal for dry or minimally draining burns and lacks inherent infection control. Given the burn's extent and infection vulnerability, silver dressing offers the best protective and therapeutic benefits.
Question 5 of 5
A nurse is caring for a client who has a pressure ulcer on the sacrum. Which intervention should the nurse perform first?
Correct Answer: D
Rationale: Repositioning the client to relieve pressure on the wound is the correct first intervention. Using the ABCDE framework (Airway, Breathing, Circulation, Disability, Exposure), relieving pressure addresses circulation by preventing further tissue ischemia, the root cause of pressure ulcers. Immediate repositioning halts ongoing damage, enhances blood flow, and sets the stage for subsequent care, making it the priority action. Applying a hydrocolloid dressing promotes healing but doesn't address the immediate threat of pressure, which must stop first. Assessing for infection is crucial but secondary, as it evaluates status rather than intervening to prevent worsening. Cleansing with saline removes debris but doesn't tackle the underlying pressure causing the ulcer. Repositioning is foundational, as unrelieved pressure will negate other interventions' effectiveness, aligning with evidence-based protocols to prioritize tissue perfusion and stop progression in pressure ulcer management.