ATI LPN
Skin Integrity and Wound Care NCLEX Questions Quizlet Questions
Question 1 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 2 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 Wet-to-dry dressings are outdated and inappropriate for dry eschar, as they're better for moist slough and can harm healthy tissue.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.
Question 3 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 4 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 5 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.