ATI LPN
Skin Integrity and Wound Care Questions Questions
Question 1 of 5
A nurse notes documentation of a stage 3 pressure ulcer in a client's record. Which of the following would the nurse expect to note on assessment of the client?
Correct Answer: B
Rationale: Stage 3 pressure ulcers involve full-thickness skin loss into the subcutaneous tissue, but not muscle or bone.
Question 2 of 5
When taking the health history for a patient, the nurse discovers that the patient works as a roofer. The nurse will plan to teach the patient about how to self-assess for clinical manifestations of
Correct Answer: D
Rationale: A patient who works as a roofer is at risk for integumentary lesions caused by sun exposure such as wrinkling, melanoma, telangiectasia, and actinic keratoses. Alopecia and intertrigo are not associated with excessive sun exposure. Melanoma is the most concerning condition among the options provided.
Question 3 of 5
An 82-year-old patient is being treated in the hospital for a sacral pressure ulcer. What age-related change is most likely to affect the patients course of treatment?
Correct Answer: D
Rationale: Wound healing becomes slower with age, requiring more time for older adults to recover from surgical and traumatic wounds.
Question 4 of 5
The nurse is caring for a burn-injured patient who weighs 154 pounds, and the burn injury covers 50% of his body surface area. The nurse calculates the fluid needs for the first 24 hours after a burn injury using a standard fluid resuscitation formula of 4 mL/kg/% burn of intravenous(IV) fluid for the first 24 hours. The nurse plans to administer what amount of fluid in the first 24 hours?
Correct Answer: C
Rationale: 154 pounds/2.2= 70 kg; 4 × 70 kg × 50= 14,000 mL, or 14 liters.
Question 5 of 5
The nurse notices small purplish dots on the abdomen of a patient. Which statement should the nurse use to document the finding?
Correct Answer: D
Rationale: Petechiae are small reddish purple hemorrhagic spots, smaller than 0.5 mm in diameter. Ecchymosis is bruising. Erythema is redness. Purpura is bleeding into the skin.