ATI LPN
Skin Integrity NCLEX Questions Questions
Question 1 of 5
A nurse is preparing to change a dressing on a client's surgical incision. Which type of dressing should the nurse use to promote autolytic debridement of the wound?
Correct Answer: D
Rationale: Hydrogel dressing is the correct answer to promote autolytic debridement in a surgical incision. Autolytic debridement uses the body's enzymes and moisture to break down necrotic tissue, and hydrogel, being water- or glycerin-based, hydrates the wound, creating an ideal moist environment for this process. This is gentle and effective for incisions with minor necrosis or slough, preserving healthy tissue. Alginate dressing is absorbent and suited for heavy exudate, not dry or minimally draining wounds needing debridement. Foam dressing cushions and absorbs moderate exudate but doesn't hydrate enough for autolysis. Gauze dressing can dry out and stick, causing trauma upon removal, and lacks the moisture retention needed for autolytic action. Hydrogel's ability to donate moisture distinguishes it, supporting natural debridement while minimizing pain and disruption, making it the best choice for this healing mechanism.
Question 2 of 5
A nurse is caring for a client who has a venous leg ulcer on the lower left calf. The nurse notes that the wound has copious amounts of yellow-green purulent drainage with a foul odor. The periwound skin is erythematous, warm, and edematous. The client reports increased pain and fever. What should the nurse do first?
Correct Answer: B
Rationale: Obtaining a wound culture and sensitivity is the correct first action for a venous leg ulcer with yellow-green purulent drainage, foul odor, erythema, edema, pain, and fever all signs of infection. Identifying the pathogen via culture guides antibiotic therapy, addressing the root cause before complications like sepsis escalate, critical in venous ulcers with poor healing potential. Compression bandages aid venous return but are secondary until infection is managed, as pressure could worsen an active infection. Analgesics and antipyretics treat symptoms, not the infection, delaying essential diagnostics. Elevation reduces edema but doesn't tackle the infection directly. Culturing first ensures targeted treatment, aligning with priority-setting in wound care to resolve infection swiftly.
Question 3 of 5
The skin is also known as the
Correct Answer: A
Rationale: Integument,' as the skin is commonly referred to as the integument or integumentary system, encompassing the external covering of the body that shields it from environmental harm. This term includes the skin itself along with its appendages like hair, nails, and glands, forming a comprehensive protective barrier. 'Epidermis' is incorrect because it's only the outermost layer of the skin, not the whole system. 'Dermis' refers to the middle layer beneath the epidermis, containing connective tissue and blood vessels, but it doesn't represent the entire skin. 'Subcutaneous' is the deepest layer, also called the hypodermis, providing insulation and fat storage, but it's distinct from the skin's broader designation. The integumentary system's holistic role in protection, sensation, and regulation distinguishes 'Integument' as the precise term, aligning with anatomical definitions and nursing fundamentals where understanding the skin's full scope is critical for patient care and wound management.
Question 4 of 5
A classification of wound that usually heals quickly, generally within days to weeks, with well-approximated edges and lessened infection risk is:
Correct Answer: B
Rationale: Acute wound,' as it describes a wound that heals quickly (days to weeks) with well-approximated edges and reduced infection risk. Acute wounds, like cuts or surgical incisions, follow a predictable healing trajectory due to minimal tissue loss and prompt repair, often via primary intention. 'Abrasion wound' is a type of injury (scraping), not a healing classification, and may heal slower if extensive. 'Chronic wound' persists beyond weeks, often due to underlying conditions like diabetes, contradicting quick healing. 'Unintentional wound' defines cause (accidental), not healing speed or edge alignment. In nursing, identifying acute wounds guides timely interventions e.g., suturing versus chronic wounds needing prolonged care. B aligns with the description's focus on healing dynamics, distinguishing it as the accurate classification over specific wound types or causation.
Question 5 of 5
Which of the following is not a psychological effect of wounds?
Correct Answer: C
Rationale: Pain,' as it's a physical, not psychological, effect of wounds. Pain results from nerve stimulation at the injury site, a sensory response, whereas psychological effects impact mental state. 'Anxiety' is psychological, reflecting worry about healing or outcomes. 'Fear' involves emotional dread, perhaps of complications. 'Changes in body image' affect self-perception, a mental shift. In nursing, distinguishing these aids holistic care pain requires analgesics, while anxiety might need counseling. The question's focus on psychological effects excludes C, as pain's physical nature contrasts with the emotional impacts of A, B, and D, aligning with wound care's mind-body framework.