ATI LPN
Skin Integrity and Wound Care NCLEX Questions Questions
Question 1 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 2 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.
Question 3 of 5
A nurse is evaluating a client's progress after receiving hyperbaric oxygen therapy (HBOT) for a chronic venous ulcer. Which outcome indicates that HBOT has been effective?
Correct Answer: D
Rationale: Increased granulation tissue in the ulcer is the correct outcome indicating hyperbaric oxygen therapy (HBOT) effectiveness for a chronic venous ulcer. HBOT delivers high-pressure oxygen to enhance tissue oxygenation, stimulating angiogenesis, collagen synthesis, and fibroblast activity, which directly boost granulation tissue formation a hallmark of healing. Reduced pain may occur but isn't specific to HBOT, as analgesics or other factors could contribute, and pain isn't a reliable healing metric. Increased blood oxygen saturation reflects systemic levels, not local tissue oxygenation, which HBOT targets, making it less relevant. Decreased edema could result from compression or elevation, not uniquely HBOT, and isn't a direct healing indicator. Granulation tissue growth ties directly to HBOT's mechanism, providing clear evidence of improved wound bed vitality and progression toward closure.
Question 4 of 5
A nurse is planning care for a client who has a surgical incision with staples. Which intervention should the nurse include in the plan to prevent wound dehiscence?
Correct Answer: B
Rationale: Instructing the client to splint the incision when coughing is the correct intervention to prevent wound dehiscence the separation of wound layers. Coughing increases intra-abdominal pressure, stressing staples, and splinting with a pillow or hands reduces tension, protecting the closure. Steri-strips approximate edges but lack the strength to prevent dehiscence under pressure, used more for minor wounds. Changing dressings every 8 hours prevents infection but doesn't address mechanical stress, and frequency depends on drainage, not a fixed schedule. Irrigating with saline cleanses but risks disrupting healing tissue, unrelated to dehiscence prevention. Splinting directly counters physical strain, aligning with post-surgical care to maintain incision integrity and promote healing.
Question 5 of 5
A client is scheduled for a skin graft surgery to treat a large wound on the arm. The nurse explains to the client that the graft will be taken from the thigh. What term should the nurse use to describe this type of graft?
Correct Answer: A
Rationale: Autograft is the correct term for a graft taken from the client's thigh to treat an arm wound. It uses the patient's own skin, minimizing rejection and infection risks while offering superior cosmetic and functional outcomes, ideal for large wounds. Allograft involves donor human skin, typically temporary, from cadavers or living donors, not the client's own tissue. Xenograft uses animal skin (e.g., pig), also temporary, for protection until an autograft is viable. Mesh graft describes a technique, not a source, where skin is slit to expand coverage, applicable to autografts or allografts. Autograft's self-sourcing distinguishes it, ensuring compatibility and long-term healing, making it the precise term for this scenario.