ATI LPN
NCLEX Questions Skin Integrity and Wound Care Questions
Question 1 of 5
A nurse participating in a research project associated with pressure ulcers will assess for what predisposing factor that tends to increase the risk for pressure ulcer development?
Correct Answer: A
Rationale: Pressure ulcers arise from unrelieved pressure impairing tissue perfusion. Decreased level of consciousness heightens risk, per nursing principles, as patients can't sense or relieve pressure, aligning with Braden Scale's sensory perception category. These patients, often bedridden or confused, miss cues to shift positions, increasing ischemic damage over bony prominences like the sacrum. Adequate dietary intake supports healing, not risk. Shortness of breath impacts oxygenation but isn't a direct factor. Muscular pain may reduce mobility but isn't primary. Research prioritizes consciousness as a measurable, prevalent risk factor nurses assess, making this the correct choice.
Question 2 of 5
Which finding will alert the nurse to a potential wound dehiscence in a postoperative patient?
Correct Answer: C
Rationale: Dehiscence wound layer separation often presents with a patient feeling something has given way' , per the flashcards, especially post-strain (e.g., coughing). Options A, B, and D are incomplete, but organ protrusion (evisceration) or drainage differ. This report triggers urgent nurse assessment, making it the correct alert.
Question 3 of 5
The nurse is caring for a patient on the medical-surgical unit with a wound that has a drain and a dressing that needs changing. Which action should the nurse take first?
Correct Answer: A
Rationale: Dressing changes hurt. Providing analgesics first , per the flashcards, eases pain 30 minutes prior, aiding cooperation. Avoiding drain removal , gloves , and supplies follow. Pain management sets the stage, making this the correct first action.
Question 4 of 5
The nurse is completing a skin risk assessment using the Braden Scale. The patient has slight sensory impairment, has skin that is rarely moist, walks occasionally, and has slightly limited mobility, along with excellent intake of meals and no apparent problem with friction and shear. Which score will the nurse document for this patient?
Correct Answer: C
Rationale: Braden scores (6-23) assess risk; higher is better. Per the flashcards: slight sensory (3), rarely moist (4), walks occasionally (3), slight mobility (3), excellent intake (4), no friction/shear (4) = 20 . This is moderate risk, making it the correct score.
Question 5 of 5
The nurse is caring for a patient with a Stage II pressure ulcer and has assigned a nursing diagnosis of Risk for infection. The patient is unconscious and bedridden. Which is the best goal for this patient?
Correct Answer: D
Rationale: Measurable goals suit unconscious patients. Remain free of odorous or purulent drainage' , per the flashcards, indicates no infection. Stating signs isn't possible. Family actions (Choices B, C) are interventions. This reflects prevention, making it the correct goal.