ATI LPN
NCLEX Questions Skin Integrity and Wound Care 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 odor from the wound is the correct answer, as it suggests a potential complication like infection or necrotic tissue, which can impede healing and lead to serious issues like sepsis. Serous drainage is normal, consisting of clear, watery fluid from capillaries, and doesn't inherently signal trouble unless excessive or cloudy. Erythema around the wound edges is expected during healing, reflecting increased blood flow and inflammation, not necessarily a complication unless it worsens or spreads. Granulation tissue in the wound bed is a positive sign of healing, indicating new tissue growth, not a problem. Foul odor, however, often accompanies bacterial overgrowth or dead tissue breakdown, requiring immediate assessment, possibly a culture, and intervention to prevent escalation, distinguishing it as a red flag among these findings.
Question 2 of 5
A client is receiving negative pressure wound therapy (NPWT) for a diabetic foot ulcer. Which action should the nurse take when changing the dressing?
Correct Answer: A
Rationale: Applying sterile saline to moisten the foam dressing before removal is the correct action during an NPWT dressing change for a diabetic foot ulcer. The foam can adhere to the wound bed, and moistening it with saline prevents trauma, pain, or bleeding upon removal, protecting fragile granulation tissue common in diabetic wounds. Cutting the foam loosely is incorrect; it should fit snugly to ensure even pressure distribution. Securing the film with tape risks air leaks; an adhesive drape extending beyond the edges is standard to maintain the seal. Disconnecting tubing from the foam first disrupts suction prematurely; it should detach from the device first to avoid pressure issues. Moistening with saline is a precise, evidence-based step to safeguard the wound, especially critical in diabetic patients with impaired healing.
Question 3 of 5
A client is admitted to the hospital with a diabetic foot ulcer. The nurse notes that the wound has black, dry, and hard tissue covering most of the wound bed. How should the nurse document this finding?
Correct Answer: A
Rationale: Eschar is the correct documentation for black, dry, and hard tissue covering a diabetic foot ulcer's wound bed. Eschar is necrotic tissue that's firm and adherent, often stable (dry, intact) or unstable (moist, loose), and in diabetic wounds, it delays healing and risks infection, requiring accurate identification. Slough is softer, moist, and typically yellow or green, not matching the dry, hard description. Fibrin is a yellowish clotting protein, not black or extensive like eschar. Exudate is fluid, not tissue, and doesn't fit. Eschar's distinct characteristics color, texture, and dryness differentiate it, and proper documentation guides treatment, like debridement, critical for diabetic wound management to prevent complications like osteomyelitis.
Question 4 of 5
A nurse is preparing to change a wet-to-dry dressing for a client who has a chronic wound on the lower leg. Which action by the nurse demonstrates proper technique?
Correct Answer: C
Rationale: Moistening the new dressing with sterile water, wringing it out, and applying it is the correct technique for a wet-to-dry dressing. This method mechanically debrides necrotic tissue as the dressing dries and adheres, lifting debris upon removal. Sterile water is preferred over saline to avoid sodium crystal formation, and wringing prevents maceration while ensuring contact with the wound bed. Soaking the old dressing reduces debridement by softening adhered tissue. Antibiotic ointment interferes with adhesion and risks resistance, countering the dressing's purpose. An occlusive cover traps moisture, promoting infection rather than drying for debridement. Proper technique with moistening and wringing balances efficacy and safety, optimizing chronic wound care.
Question 5 of 5
Which of the functions of the skin is defined as 'water, electrolytes, and nitrogenous wastes are excreted in small amounts of sweat'
Correct Answer: D
Rationale: Elimination,' as this function describes the skin's role in excreting water, electrolytes, and nitrogenous wastes through sweat. Sweat glands produce sweat, a mixture containing these substances, aiding in waste removal and electrolyte balance, albeit in small amounts compared to kidneys. 'Protection' refers to the skin's barrier against pathogens and injury, not excretion. 'Sensation' involves nerve endings detecting stimuli, unrelated to waste. 'Regulation' covers temperature control via sweating or vasoconstriction, but the question specifies excretion, not thermoregulation. Elimination uniquely fits, as it's a recognized skin function in physiology, crucial for nursing knowledge in fluid balance and patient assessment e.g., excessive sweating might signal electrolyte loss. This specificity distinguishes 'Elimination' as the precise answer, aligning with the skin's excretory role.