ATI LPN
Skin Integrity NCLEX Questions Questions
Question 1 of 5
A nurse is providing care to a client and has enlisted the help of a trained interpreter to assist in communicating with the client. Which action would the nurse take?
Correct Answer: B
Rationale: Interpreters must focus on language. Speaking privately to limit to interpretation , per the rationale, aligns with CLAS Standards, ensuring accuracy without advice. Apps miss nuance. Continuing unchecked risks errors. Documenting falsely misrepresents. This upholds client autonomy and communication rights, making it correct.
Question 2 of 5
The registered nurse (RN) directs the licensed practical nurse (LPN) to assist with the care of a client who has a sacral pressure injury. Which is the most appropriate activity for the RN to delegate to the LPN?
Correct Answer: A
Rationale: LPN scope includes basic care. Positioning , per nursing delegation standards (e.g., NCSBN), suits LPN skills, aiding pressure relief. Initiating protocols or determining plans (Choice D, incomplete) require RN judgment. Meeting (Choice C, incomplete) is vague but likely RN-level. Delegation optimizes care safely, making this the most appropriate activity.
Question 3 of 5
A client has a venous ulcer on the lower leg that is treated with compression therapy. The nurse instructs the client to elevate the leg above the level of the heart whenever possible. What is the rationale for this instruction?
Correct Answer: A
Rationale: Choice A is correct because elevating the leg above the heart reduces edema and venous pressure, which is the primary rationale for this instruction in managing a venous ulcer. Venous ulcers stem from chronic venous insufficiency, causing blood pooling, increased pressure, and swelling in the lower legs. Elevation leverages gravity to enhance venous return to the heart, alleviating these issues and supporting healing. Increasing arterial blood flow and oxygenation is more relevant to arterial ulcers, where elevation might worsen perfusion by countering gravity's aid to arterial flow. Preventing infection and inflammation is critical but not directly tied to elevation; it relies more on wound care practices like cleansing and dressings. Stimulating nerve regeneration and sensation is unrelated to venous ulcers or elevation, as neuropathy isn't a primary concern here. Thus, reducing edema and venous pressure best explains the benefit of elevation in this context.
Question 4 of 5
A nurse is assessing a client with a pressure ulcer on the sacrum. Which finding indicates a potential complication of the wound?
Correct Answer: C
Rationale: Foul-smelling greenish discharge is the correct answer, indicating a potential complication such as infection in the pressure ulcer. This type of discharge, often linked to bacteria like Pseudomonas, combined with a foul odor, suggests microbial overgrowth that can hinder healing and lead to serious outcomes like sepsis if untreated. Prompt reporting and a wound culture are critical to identify the pathogen and tailor treatment. Serous drainage is typically clear and watery, a normal part of healing unless it becomes excessive or purulent. Redness and warmth around the wound are expected signs of inflammation and increased blood flow during early healing stages, not necessarily problematic unless accompanied by worsening symptoms. Granulation tissue is a healthy sign, showing new tissue growth and vascularization, not a complication. The distinct foul-smelling, greenish discharge stands out as an abnormal finding requiring immediate attention, distinguishing it from the other options.
Question 5 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.