ATI LPN
NCLEX Style Questions on Skin Integrity and Wound Care Questions
Question 1 of 5
A nurse is performing a skin assessment of a client who is immobile and notes the presence of partial thickness skin loss of the upper layer of the skin in the sacral area. The nurse documents these findings as a:
Correct Answer: B
Rationale: Stage 2 pressure ulcers involve partial-thickness loss of the epidermis and/or dermis, as described.
Question 2 of 5
The nurse is performing an initial assessment of a patient who has a raised, pruritic rash. The patient denies taking any prescription medication and denies any allergies. What would be an appropriate question to ask this patient at this time?
Correct Answer: C
Rationale: If suspicious areas are noted, the patient is questioned about nonprescription or herbal preparations that might be in use.
Question 3 of 5
When paramedics notice singed hairs in the nose of a burn patient, it is recommended that the patient be intubated. What is the reasoning for the immediate intubation?
Correct Answer: B
Rationale: In inhalation injury, the airway may become edematous quickly, making intubation difficult. Early intubation is recommended to protect the airway. Carbon monoxide poisoning may be present, but singed nose hairs are neither a symptom nor a reason for early intubation. Management of secretions is not an indication for intubation. Singed hairs and soot are more commonly symptoms of injury above the glottis rather than lower airway, below-the-glottis, signs and symptoms that will interfere with oxygenation and ventilation.
Question 4 of 5
The nurse is applying wet dressings as ordered to a patient who has a crusted skin lesion. Which assessment finding should cause the nurse the most concern?
Correct Answer: B
Rationale: Wet dressings should not be prescribed for more than 72 hours, because the skin may become too dry or macerated. Oiliness, edema, and oozing are not common reactions to wet dressings.
Question 5 of 5
A nurse is preparing to discharge a patient from the emergency department after receiving treatment for an ankle sprain. While providing discharge education, the nurse should encourage which of the following?
Correct Answer: D
Rationale: Treatment of a sprain consists of resting and elevating the affected part, applying cold, and using a compression bandage. After the acute inflammatory stage (usually 24 to 48 hours after injury), heat may be applied intermittently. Rotation exercises would likely be painful.