ATI RN
NCLEX Questions Skin Integrity and Wound Care Questions
Question 1 of 5
A nurse is assessing wound drainage during the immediate postoperative period for a patient who has had a breast removed. In addition to assessing the dressing, where would the nurse also check for drainage?
Correct Answer: B
Rationale: Under the patient' is checked post-mastectomy. Drainage e.g., 50 mL pools e.g., bed unlike 'under skin' , internal e.g., not visible. 'Output sheet' records e.g., not site. 'Axilla' is near e.g., not primary. A nurse lifts e.g., Check below' per 80% drainage catch, a physiological need. The text specifies this, making the correct, additional spot.
Question 2 of 5
The nurse is assessing a group of older adults. Which client is at greatest risk for skin breakdown? A person who has:
Correct Answer: B
Rationale: Correct Answer: B - Reduced sensation of pressure Rationale: 1. Reduced sensation of pressure leads to decreased ability to feel discomfort and adjust position, increasing risk of prolonged pressure on the skin. 2. Prolonged pressure can cause tissue damage and skin breakdown, especially in older adults with fragile skin. 3. Proper sensation of pressure is crucial for individuals to respond to discomfort and prevent pressure ulcers. Summary of Other Choices: A. Altered balance: While altered balance can increase the risk of falls, it is not directly related to skin breakdown. C. Impaired hearing ability: Impaired hearing may affect communication but does not directly impact skin breakdown. D. Impaired visual acuity: Impaired vision can affect safety and mobility but is not a primary risk factor for skin breakdown.
Question 3 of 5
Which goal will the nurse include in Aaron's plan of care?
Correct Answer: A
Rationale: The correct answer is A because maintaining intact skin is a priority in nursing care to prevent skin breakdown and pressure ulcers. This goal ensures the client's overall health and quality of life. Choice B is incorrect as restoring motor function may not be a priority depending on the client's condition. Choice C is incorrect as client teaching is important but not the primary goal in this scenario. Choice D is incorrect as preventing impaired skin integrity is not as effective as ensuring the skin remains intact.
Question 4 of 5
What initial action should the nurse take when Aaron expresses frustration?
Correct Answer: B
Rationale: The correct initial action for the nurse to take when Aaron expresses frustration is to offer him the opportunity to discuss his feelings of anger and hopelessness (Choice B). This is the best approach because it shows empathy and allows Aaron to express his emotions, which can help in understanding the root cause of his frustration. Confronting him (Choice A) may escalate the situation and worsen his behavior. Involving Aaron's parents (Choice C) without first addressing Aaron's feelings directly may not be effective. Lastly, reassuring him about his future hospital visits (Choice D) does not address the current emotional distress he is experiencing. In summary, Choice B is the most appropriate as it focuses on addressing Aaron's emotions and providing a supportive environment for him to express his frustrations.
Question 5 of 5
The nurse is caring for a client who is being discharged following abdominal surgery with an incision. Which instruction is most important for the nurse to teach this client regarding wound healing?
Correct Answer: D
Rationale: The correct answer is D because it emphasizes the importance of monitoring for signs of infection, such as swelling, warmth, or tenderness, which are crucial in detecting complications early. This instruction ensures prompt medical intervention if needed, promoting proper wound healing. A: Thoroughly irrigating the wound with hydrogen peroxide once a day can be too harsh and may delay healing by damaging healthy tissue. B: Applying a lubricating lotion to the edges of the wound may not address infection risk or proper wound care. C: Adding more fruits and vegetables to the diet is beneficial for overall health but not directly related to wound healing or preventing complications.