ATI LPN
Skin Integrity and Wound Care NCLEX Questions Quizlet Questions
Question 1 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 2 of 5
A nurse is assessing a client with a pressure ulcer on the sacrum. Which finding should the nurse report to the provider immediately?
Correct Answer: A
Rationale: Foul odor and purulent drainage is the correct finding to report immediately, as it signals an acute infection in the pressure ulcer. This combination suggests bacterial proliferation, potentially leading to sepsis or deeper tissue damage, requiring urgent provider intervention, wound culture, and possibly antibiotics. Black, necrotic tissue indicates eschar, which needs debridement but isn't immediately life-threatening unless unstable or infected, manageable by the wound team. Red, granulating tissue is a healthy sign of healing, not a concern. Yellow, sloughing tissue represents slough, which delays healing but isn't an emergency unless paired with infection signs. The foul odor and purulent drainage escalate the situation to critical, demanding prompt reporting to prevent systemic complications, distinguishing it as the priority among these findings.
Question 3 of 5
A client has a stage 3 pressure ulcer on the left trochanter with moderate serosanguineous drainage. The wound is $4 cm in length, $3 cm in width, and $2 cm in depth. The wound bed is $80% granulation tissue and $20% slough. Which type of dressing should the nurse use for this wound?
Correct Answer: C
Rationale: Alginate is the correct dressing for a stage 3 pressure ulcer with moderate serosanguineous drainage, depth, and mixed tissue. Derived from seaweed, alginate absorbs moderate to heavy exudate (up to 20 times its weight), forming a gel that maintains moisture, supports autolytic debridement of the 20% slough, and fills the 2 cm depth, promoting healing. Hydrocolloid suits minimal drainage, risking maceration in deeper, exudative wounds. Hydrogel hydrates dry wounds but can't handle moderate drainage, potentially leaking. Transparent film is non-absorbent, unfit for exudate or depth, and better for superficial wounds. Alginate's absorbency and adaptability make it ideal for this wound's characteristics, balancing moisture and clearing debris effectively.
Question 4 of 5
A nurse is assessing a client who has a wound on the abdomen. The nurse observes that the wound edges are approximated, there is minimal drainage, and granulation tissue is visible. How should the nurse document this wound?
Correct Answer: C
Rationale: Primary intention wound is the correct documentation for a wound with approximated edges, minimal drainage, and visible granulation tissue. This healing type occurs when edges are closed (e.g., by sutures), minimizing tissue loss and scarring, with granulation supporting epithelialization. Partial-thickness involves only epidermis and part of dermis, healing by regeneration, not matching the deeper granulation here. Full-thickness extends to subcutaneous layers, healing with significant scarring, not minimal drainage. Secondary intention involves open wounds with extensive loss, healing slowly via granulation and contraction, not approximated edges. Primary intention fits the orderly, efficient healing observed, reflecting a controlled closure process typical of surgical or well-managed wounds.
Question 5 of 5
A characteristic of an unintentional wound is:
Correct Answer: D
Rationale: A and C,' as unintentional wounds are characterized by being accidental and often having clean edges, depending on the cause. 'Accidental' fits because unintentional wounds result from unplanned events like falls or cuts, not deliberate actions like surgery. 'Clean edges' applies to wounds from sharp objects (e.g., a knife slice), common in accidents, though not universal jagged edges can occur too. 'High risk for infection' isn't exclusive to unintentional wounds; it depends on contamination, not intent, and intentional wounds (e.g., surgical) can also get infected if mishandled. Combining A and C captures key traits without overgeneralizing infection risk. In nursing, recognizing these features aids assessment accidental wounds may need tetanus prophylaxis, and clean edges suggest primary closure potential. 'All of the above' (E) overstates infection specificity, making D the precise choice per wound classification principles.