ATI LPN
Skin Integrity and Wound Care NCLEX Questions Quizlet Questions
Question 1 of 5
A nurse is conducting a cultural assessment of a client. Which person would the nurse identify as the expert?
Correct Answer: C
Rationale: The client is the cultural expert. Per the rationale provided, the client knows their own beliefs best, per Giger and Davidhizar's model, guiding care (e.g., spiritual practices). Nurses and providers gather data, not define it. Family supplements, not overrides. Recognizing the client as expert ensures patient-centeredness, avoiding assumptions, making this the correct choice.
Question 2 of 5
The registered nurse is observing a newly hired nurse perform a dressing change on a client with a leg ulcer. An enzymatic agent is being used to treat the ulcer. Which observation, if made by the registered nurse, would indicate a need for further teaching with the newly hired nurse?
Correct Answer: B
Rationale: Enzymatic agents need moisture. Wrapping with gauze , per wound care protocols, traps the agent, risking healthy tissue damage; it should stay exposed or loosely covered. Saline cleansing and necrosis application are correct. Open air aligns with use. Further teaching ensures debridement efficacy, making this the incorrect action.
Question 3 of 5
A nurse is evaluating the effectiveness of negative pressure wound therapy (NPWT) on a client with a chronic wound. Which of the following outcomes would indicate that the therapy is successful?
Correct Answer: B
Rationale: as decreased drainage indicates successful negative pressure wound therapy (NPWT). NPWT uses a vacuum to remove excess fluid, debris, and infectious material from the wound, reducing drainage, edema, and bacterial load while promoting blood flow and granulation tissue formation key signs of healing. An increase in wound size suggests worsening or tissue damage, countering NPWT's goal of wound closure. Increased pain could indicate complications like infection or improper application, not success, as NPWT should enhance comfort by reducing inflammation. Decreased granulation tissue would signal poor healing, as NPWT aims to stimulate this tissue's growth, not diminish it. Decreased drainage aligns with NPWT's mechanism of action, reflecting effective fluid management and progression toward wound recovery.
Question 4 of 5
A nurse is evaluating a client's response to negative pressure wound therapy (NPWT). Which outcome indicates that the therapy is effective?
Correct Answer: A
Rationale: Decreased edema in the wound area is the correct answer, as it shows negative pressure wound therapy (NPWT) is working effectively. NPWT applies suction to remove excess fluid, reducing swelling, improving circulation, and fostering a healing environment by decreasing edema. Increased drainage would suggest NPWT isn't managing fluid properly, as it should reduce, not increase, exudate. Decreased granulation tissue indicates poor healing, as NPWT aims to boost this tissue's growth, not diminish it. Increased eschar reflects failure, as NPWT should aid debridement, not promote necrotic tissue buildup. Reduced edema aligns with NPWT's mechanism enhancing blood flow and fluid removal making it a clear indicator of success in supporting wound recovery.
Question 5 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: Consulting with the provider about surgical debridement is the correct action for a diabetic foot ulcer with black, dry, hard eschar. Eschar indicates significant necrotic tissue, which delays healing and heightens infection risk in diabetic patients, who are prone to complications due to poor vascularity and immune response. Surgical debridement swiftly removes this barrier, exposing viable tissue for healing, and is the most efficient method for extensive necrosis. Wet-to-dry dressings are outdated and inappropriate for dry eschar, as they're better for moist slough and can harm healthy tissue. Transparent film traps moisture but doesn't address necrosis, risking infection beneath the eschar. Leaving it open to air invites contamination and drying, slowing recovery. Given the wound's severity and diabetes context, consulting for surgical intervention ensures timely, effective management, reducing risks like osteomyelitis or amputation.