ATI LPN
NCLEX Style Questions on Skin Integrity and Wound Care Questions
Question 1 of 5
A nurse is assessing the operative site in a client who underwent a breast reconstruction. The nurse is inspecting the flap and the areola of the nipple and notes that the areola is a deep red color around the edge. The nurse takes which action first?
Correct Answer: D
Rationale: Deep red color may indicate vascular compromise or infection, requiring immediate physician evaluation.
Question 2 of 5
While waiting to see the physician, a patient shows the nurse skin areas that are flat, nonpalpable, and have had a change of color. The nurse recognizes that the patient is demonstrating what?
Correct Answer: A
Rationale: A macule is a flat, nonpalpable skin color change, while a papule is an elevated, solid, palpable mass. A vesicle is a circumscribed, elevated, palpable mass containing serous fluid, while a pustule is a pus-filled vesicle.
Question 3 of 5
The nurse is performing an initial assessment of a patient who has a raised, pruritic rash. The patient denies taking any prescription medication and denies any allergies. What would be an appropriate question to ask this patient at this time?
Correct Answer: C
Rationale: If suspicious areas are noted, the patient is questioned about nonprescription or herbal preparations that might be in use.
Question 4 of 5
When paramedics notice singed hairs in the nose of a burn patient, it is recommended that the patient be intubated. What is the reasoning for the immediate intubation?
Correct Answer: B
Rationale: In inhalation injury, the airway may become edematous quickly, making intubation difficult. Early intubation is recommended to protect the airway. Carbon monoxide poisoning may be present, but singed nose hairs are neither a symptom nor a reason for early intubation. Management of secretions is not an indication for intubation. Singed hairs and soot are more commonly symptoms of injury above the glottis rather than lower airway, below-the-glottis, signs and symptoms that will interfere with oxygenation and ventilation.
Question 5 of 5
The nurse is applying wet dressings as ordered to a patient who has a crusted skin lesion. Which assessment finding should cause the nurse the most concern?
Correct Answer: B
Rationale: Wet dressings should not be prescribed for more than 72 hours, because the skin may become too dry or macerated. Oiliness, edema, and oozing are not common reactions to wet dressings.