ATI LPN
Skin Integrity NCLEX Questions Questions
Question 1 of 5
A nurse is assessing a client with a pressure ulcer on the sacrum. Which finding indicates a potential complication of the wound?
Correct Answer: C
Rationale: Foul-smelling greenish discharge is the correct answer, indicating a potential complication such as infection in the pressure ulcer. This type of discharge, often linked to bacteria like Pseudomonas, combined with a foul odor, suggests microbial overgrowth that can hinder healing and lead to serious outcomes like sepsis if untreated. Prompt reporting and a wound culture are critical to identify the pathogen and tailor treatment. Serous drainage is typically clear and watery, a normal part of healing unless it becomes excessive or purulent. Redness and warmth around the wound are expected signs of inflammation and increased blood flow during early healing stages, not necessarily problematic unless accompanied by worsening symptoms. Granulation tissue is a healthy sign, showing new tissue growth and vascularization, not a complication. The distinct foul-smelling, greenish discharge stands out as an abnormal finding requiring immediate attention, distinguishing it from the other options.
Question 2 of 5
A client with venous insufficiency has a venous stasis ulcer on the lower leg. Which instruction should the nurse give to the client to promote wound healing?
Correct Answer: D
Rationale: All of the above,' is correct, as all listed instructions applying compression stockings or bandages , avoiding crossing legs or tight clothing , and keeping the leg elevated promote healing of a venous stasis ulcer. Venous insufficiency causes blood pooling, edema, and pressure, impairing wound recovery. Compression therapy enhances venous return, reducing swelling and supporting circulation. Avoiding leg crossing or tight garments prevents vessel constriction, maintaining blood flow. Elevation above heart level uses gravity to drain fluid, alleviating edema and pressure. Each action targets a facet of venous ulcer pathology, and together, they form a comprehensive strategy to improve oxygenation, reduce inflammation, and accelerate healing, making D the most inclusive and effective choice for patient education in this chronic condition.
Question 3 of 5
A nurse is caring for a client who has a venous leg ulcer on the lower left calf. The nurse notes that the wound has copious amounts of yellow-green purulent drainage with a foul odor. The periwound skin is erythematous, warm, and edematous. The client reports increased pain and fever. What should the nurse do first?
Correct Answer: B
Rationale: Obtaining a wound culture and sensitivity is the correct first action for a venous leg ulcer with yellow-green purulent drainage, foul odor, erythema, edema, pain, and fever all signs of infection. Identifying the pathogen via culture guides antibiotic therapy, addressing the root cause before complications like sepsis escalate, critical in venous ulcers with poor healing potential. Compression bandages aid venous return but are secondary until infection is managed, as pressure could worsen an active infection. Analgesics and antipyretics treat symptoms, not the infection, delaying essential diagnostics. Elevation reduces edema but doesn't tackle the infection directly. Culturing first ensures targeted treatment, aligning with priority-setting in wound care to resolve infection swiftly.
Question 4 of 5
The skin is also known as the
Correct Answer: A
Rationale: Integument,' as the skin is commonly referred to as the integument or integumentary system, encompassing the external covering of the body that shields it from environmental harm. This term includes the skin itself along with its appendages like hair, nails, and glands, forming a comprehensive protective barrier. 'Epidermis' is incorrect because it's only the outermost layer of the skin, not the whole system. 'Dermis' refers to the middle layer beneath the epidermis, containing connective tissue and blood vessels, but it doesn't represent the entire skin. 'Subcutaneous' is the deepest layer, also called the hypodermis, providing insulation and fat storage, but it's distinct from the skin's broader designation. The integumentary system's holistic role in protection, sensation, and regulation distinguishes 'Integument' as the precise term, aligning with anatomical definitions and nursing fundamentals where understanding the skin's full scope is critical for patient care and wound management.
Question 5 of 5
A classification of wound that usually heals quickly, generally within days to weeks, with well-approximated edges and lessened infection risk is:
Correct Answer: B
Rationale: Acute wound,' as it describes a wound that heals quickly (days to weeks) with well-approximated edges and reduced infection risk. Acute wounds, like cuts or surgical incisions, follow a predictable healing trajectory due to minimal tissue loss and prompt repair, often via primary intention. 'Abrasion wound' is a type of injury (scraping), not a healing classification, and may heal slower if extensive. 'Chronic wound' persists beyond weeks, often due to underlying conditions like diabetes, contradicting quick healing. 'Unintentional wound' defines cause (accidental), not healing speed or edge alignment. In nursing, identifying acute wounds guides timely interventions e.g., suturing versus chronic wounds needing prolonged care. B aligns with the description's focus on healing dynamics, distinguishing it as the accurate classification over specific wound types or causation.