ATI LPN
NCLEX Skin Integrity Questions Questions
Question 1 of 5
A nurse plans care for a client who has a wound that is not healing. Which focused assessment should the nurse complete next to develop the client's plan of care?
Correct Answer: D
Rationale: Nutritional status can have a significant impact on wound healing. Prealbumin laboratory results provide information related to protein deficiencies, which are critical for wound healing.
Question 2 of 5
A nurse cares for a client who has burn injuries. The client's wife asks, 'When will his high risk for infection decrease?' How should the nurse respond?
Correct Answer: D
Rationale: Intact skin is a major barrier to infection; risk remains high until all wounds close.
Question 3 of 5
A dark-skinned patient has been admitted to the hospital with chronic heart failure. How would the nurse best assess this patient for cyanosis?
Correct Answer: C
Rationale: Cyanosis in dark-skinned individuals is more easily seen in the mucous membranes. Earlobe color may change in light-skinned individuals, but this change in skin color is difficult to detect on darker skin. Application of pressure to the palms of the hands and nail bed assessment would check for adequate circulation but not for skin color.
Question 4 of 5
What is the best method to prevent the spread of infection when the nurse is changing the dressing over a wound infected with Staphylococcus aureus?
Correct Answer: D
Rationale: Careful hand washing and the safe disposal of soiled dressings are the best means of preventing the spread of skin problems. Sterile glove and sterile saline use during wound care will not necessarily prevent spread of infection. Applying antibiotic ointment will treat the bacteria but not necessarily prevent the spread of infection.
Question 5 of 5
The client is admitted with full-thickness and partial-thickness burns to more than 30% of the body. The nurse is concerned with the client's nutritional status. Which intervention should the nurse implement?
Correct Answer: A
Rationale: Encouraging favorite foods supports increased caloric intake needed for healing in burn patients with high metabolic demands.