ATI LPN
Skin Integrity and Wound Care NCLEX Questions Quizlet Questions
Question 1 of 5
A nurse is caring for a patient with a wound. Which assessment data will be most relevant with regard to wound healing?
Correct Answer: B
Rationale: Pulse oximetry , per the flashcards, assesses oxygen saturation crucial for wound healing, as hypoxia delays repair. Muscular strength aids mobility, not healing directly. Options C and D are missing. Nurses ensure oxygenation (>90%) supports cellular repair, making this the correct data.
Question 2 of 5
The nurse is caring for a patient with a Stage IV pressure ulcer. Which nursing diagnosis should the nurse add to the care plan?
Correct Answer: C
Rationale: Stage IV ulcers warrant Impaired skin integrity' , per NANDA-I, as the primary issue, per the flashcards. Nutrition is a goal. Mobility and pain may coexist. This drives wound care, making it the correct diagnosis.
Question 3 of 5
The nurse is performing a moist-to-dry dressing. In which order will the nurse implement the steps, starting with the first one? (1. Apply sterile gloves, 2. Cover and secure topper dressing, 3. Assess wound and surrounding skin, 4. Moisten gauze with prescribed solution, 5. Gently wring out excess solution and unfold, 6. Loosely pack until all wound surfaces are in contact with gauze)
Correct Answer: B
Rationale: Moist-to-dry dressing sequence, per nursing practice, starts with sterile gloves (1) for infection control , then assesses wound (3), moistens gauze (4), wrings out (5), packs (6), and secures (2). Starting with moistening (Choices A, C) skips sterility. Moistening before assessing is illogical. This order ensures safety and efficacy, making it the correct sequence.
Question 4 of 5
The nurse is cleansing a wound site. Which intervention should the nurse include when cleansing the wound site?
Correct Answer: A
Rationale: Cleansing from least to most contaminated (implied with Choice A), per nursing practice, prevents infection spread, using clean gauze/gloves. Options B-D are missing, but vigorous scrubbing or reverse flow don't fit. This standard ensures safety, making it the correct intervention.
Question 5 of 5
A nurse who works with clients from different cultures wants to understand the invisible elements of culture. Which is an example of an invisible cultural element?
Correct Answer: A
Rationale: Invisible cultural elements shape behavior subtly. Notions of time , per cultural competence models (e.g., Giger and Davidhizar), vary like punctuality versus fluidity and influence care (e.g., appointment adherence). Clothing , foods , and language are visible. Nurses must grasp invisible aspects to avoid miscommunication, as time perception affects trust and compliance, making this the correct example.