ATI LPN
NCLEX Practice Questions Skin Integrity and Wound Care Questions
Question 1 of 5
A nurse leaves a pressure ulcer open to air without a dressing. To which patient did the nurse provide care?
Correct Answer: A
Rationale: Stage I pressure ulcers intact skin with nonblanchable redness heal without dressings (Choice A), per the text, resolving in 7-14 days with pressure relief. Stage II requires moisture-retentive dressings like hydrocolloids for partial-thickness loss. Stage III and IV need advanced dressings (e.g., hydrogels) for deeper damage. Open-to-air is appropriate only for Stage I, as it avoids unnecessary intervention while promoting natural recovery, making this the correct patient for the nurse's care approach.
Question 2 of 5
A new nurse is delegating care of a chronic, nonsterile wound to a UAP. What action by the new nurse causes the preceptor to intervene?
Correct Answer: A
Rationale: Wound assessment is a nursing responsibility and cannot be delegated to UAP.
Question 3 of 5
The nurse is educating the patient about the use of heat/cold therapy at home. Which statement by the patient indicates the need for further education?
Correct Answer: C
Rationale: Hot packs should not be microwaved unless designed for it, indicating a need for clarification.
Question 4 of 5
The nurse identifies which skin layer that delivers the blood supply to the dermis, provides insulation, and has a cushioning effect?
Correct Answer: C
Rationale: The subcutaneous layer supplies blood to the dermis and provides insulation and cushioning.
Question 5 of 5
The nurse is caring for a patient with a Stage IV pressure ulcer. Which type of healing will the nurse consider when planning care for this patient?
Correct Answer: B
Rationale: Stage IV ulcers, exposing bone or muscle, heal via full-thickness repair , per the text, involving four phases (hemostasis, inflammatory, proliferative, maturation) due to extensive loss. Partial-thickness suits shallow wounds. Primary intention is for closed incisions. Tertiary intention delays closure. Nurses plan debridement and grafting for full-thickness, per evidence-based care, making this the correct healing type.