ATI LPN
NCLEX Questions Medication Administration Questions
Question 1 of 5
A nurse is caring for a client who has a surgical incision with sutures. The nurse observes that the edges of the wound are well approximated and there is minimal drainage from the site. The nurse documents this type of wound healing as:
Correct Answer: A
Rationale: Primary intention is a type of wound healing that occurs when the edges of the wound are well approximated and there is minimal tissue loss or infection. It results in minimal scarring and fast healing.
Question 2 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 from the wound indicates a possible infection, which can delay wound healing and increase the risk of sepsis. The nurse should notify the provider and obtain a wound culture to identify the causative organism and guide antibiotic therapy.
Question 3 of 5
A client is admitted to the hospital with a diabetic foot ulcer. The nurse notes that the wound has a black, dry, and hard eschar covering most of its surface. Which action should the nurse take?
Correct Answer: D
Rationale: The nurse should consult with the provider about surgical debridement for a wound that has a black, dry, and hard eschar covering most of its surface. This type of eschar indicates necrotic tissue that impairs wound healing and increases the risk of infection. Surgical debridement is the most effective method of removing large amounts of necrotic tissue from a wound.
Question 4 of 5
A nurse is evaluating a client's progress after receiving hyperbaric oxygen therapy (HBOT) for a chronic venous ulcer. Which outcome indicates that HBOT has been effective?
Correct Answer: D
Rationale: The client has increased granulation tissue in the ulcer, which indicates that HBOT has been effective in enhancing wound healing. HBOT delivers 100% oxygen at high pressure to increase oxygen delivery and diffusion to hypoxic tissues, stimulating angiogenesis, collagen synthesis, and fibroblast proliferation.
Question 5 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 dead tissue that is black, dry, and hard and adheres firmly to the wound bed or ulcer edges. It may be stable (dry, adherent, intact without erythema or fluctuance) or unstable (loose, moist, boggy, edematous). Stable eschar on the heels serves as the body's natural cover and should not be removed. Unstable eschar in infected wounds should be debrided to expose viable tissue.