ATI RN
NCLEX Practice Questions Skin Integrity and Wound Care Questions
Question 1 of 5
A nurse is assessing a patient with a stage IV pressure ulcer. What assessment of the ulcer would be expected?
Correct Answer: A
Rationale: Full-thickness skin loss' fits a Stage IV ulcer. Deep e.g., bone visible defines it e.g., 20% cases unlike 'pallor' , Stage I e.g., intact. 'Blisters' are Stage II e.g., partial. 'Eschar' may occur e.g., not required. A nurse expects e.g., Deep hole' per NPUAP, a physiological marker. The text specifies full loss, making the correct, expected finding.
Question 2 of 5
A nurse is providing care for four clients on a medical-surgical unit. Which of the following clients should the nurse identify as being at risk for the development of pressure ulcers? (Select the one that does not apply.)
Correct Answer: A
Rationale: The correct answer is A because a client who is ambulatory following a cardiac catheterization is not at risk for developing pressure ulcers. Pressure ulcers are caused by sustained pressure on the skin, leading to tissue damage. Clients who are immobile, have poor circulation, or poor nutrition are at higher risk. Explanation for incorrect choices: B: A client with hyperglycemia may have impaired wound healing but is not directly at risk for pressure ulcers. C: Protein-calorie malnutrition can lead to impaired tissue healing and increase the risk of pressure ulcers. D: Right-sided heart failure and edema increase pressure on the skin, leading to an increased risk of pressure ulcers.
Question 3 of 5
During the assessment of these high-risk areas, the nurse finds no redness, but the underlying tissue feels spongy. What action should the nurse implement?
Correct Answer: D
Rationale: Correct Answer: D Rationale: 1. Spongy underlying tissue indicates possible pressure damage, not inflammation (A). 2. Excessive fluid retention is unrelated to spongy tissue and requires medical evaluation, not just notification (B). 3. Reassurance without proper assessment and intervention is inadequate and potentially harmful (C). 4. Identifying the areas as sites of pressure damage is crucial for implementing appropriate interventions and preventing further harm.
Question 4 of 5
What equipment will the nurse use to assess the length of a sinus tract?
Correct Answer: C
Rationale: The correct answer is C: Sterile cotton-tipped applicator. The nurse will use this equipment to assess the length of a sinus tract by gently inserting the applicator into the tract until resistance is felt, then marking the length on the applicator. Sterile gloves and lubricant (A) are used for wound care but not specifically for measuring the length of a sinus tract. Sterile tape measure (B) is not suitable for measuring inside a tract. Sterile irrigation tray with syringe (D) is used for wound irrigation, not for measuring the length of a sinus tract.
Question 5 of 5
A nurse is planning an in-service on preventing infection for the staff nurses on a hospital's medical-surgical unit. Which of the following should be the priority teaching point for this in-service?
Correct Answer: D
Rationale: The correct answer is D: Performing hand hygiene. Hand hygiene is the most effective way to prevent the spread of infection in a healthcare setting. By washing hands thoroughly and regularly, healthcare workers can reduce the transmission of pathogens between patients and themselves. This is crucial in preventing healthcare-associated infections. Raising the temperature in each client's room (Choice A) is not an effective method for preventing infection transmission. Assessing vital signs once daily (Choice B) is important for monitoring patient health but is not directly related to preventing infection. Wearing a mask for client care (Choice C) is important in certain situations, but hand hygiene is a more universal and crucial practice for infection prevention. In summary, performing hand hygiene is the priority teaching point as it is the most effective and fundamental measure in preventing infection transmission in a healthcare setting.