ATI RN
Skin Integrity NCLEX Questions Questions
Question 1 of 5
A nurse who works on the orthopedic unit has just received change-of-shift report. Which patient should the nurse assess first?
Correct Answer: B
Rationale: The correct answer is B because urinary retention post-laminectomy can lead to serious complications like bladder distension and renal impairment. Assessing and addressing the patient's voiding status promptly is crucial. Choices A, C, and D all have important issues but do not pose immediate risks to the patient's physiological stability compared to urinary retention.
Question 2 of 5
A thermal burn described as involving the entire epidermis and dermis is classified as:
Correct Answer: D
Rationale: The correct answer is D: Full-thickness second degree. This classification indicates a burn that extends through the entire epidermis and dermis. The term "full-thickness" implies involvement of both layers. Choice A (full third degree) is incorrect as it implies deeper tissue involvement beyond the dermis. Choice B (deep first degree) is incorrect as it suggests involvement of only the epidermis and deeper layers. Choice C (partial second degree) is incorrect because it implies involvement of only part of the dermis, not the entire thickness. Therefore, the most accurate classification for a burn involving the entire epidermis and dermis is full-thickness second degree.
Question 3 of 5
A woman has just delivered a child with a hemangioma on his right cheek area. The mother clutches the nurse and asks, “What is that thing on his face?” The nurse will respond with which of the following facts? Select all that apply.
Correct Answer: A
Rationale: Rationale: 1. Hemangiomas are commonly referred to as "strawberry birthmarks" due to their red, raised appearance. 2. They are common in newborns and usually appear within the first few weeks of life. 3. Hemangiomas typically grow in size initially, then gradually shrink over time without any treatment. 4. Most hemangiomas do not cause any health issues and are not cancerous. 5. Therefore, choice A is correct as it accurately explains the nature and commonality of hemangiomas in newborns. Other choices are incorrect as they do not align with the typical characteristics and outcomes of hemangiomas, such as rapid growth followed by regression, permanence, or the need for close monitoring in case of ulceration.
Question 4 of 5
The nurse notes a reddened area on the right heel that does not turn lighter in color when pressed with a finger. Which term will the nurse use to describe this area?
Correct Answer: D
Rationale: The nurse identifies 'nonblanchable erythema' for a reddened right heel that doesn't lighten under pressure, indicating early tissue damage, per Potter's *Essentials* (9th Ed.). This Stage 1 pressure injury sign e.g., persistent redness over 30 minutes shows capillary occlusion, unlike 'reactive hyperemia' , which blanches e.g., fades in seconds from temporary blood rush. 'Secondary erythema' isn't a term e.g., no such condition exists in wound care. 'Blanchable hyperemia' lightens e.g., normal response to pressure relief. A nurse pressing e.g., no color shift notes nonblanchable's risk (e.g., 50% progress to ulcers), per NPUAP, needing intervention (e.g., offloading). Unlike reactive's fleeting flush or blanchable's safety, nonblanchable signals deep ischemia, a key assessment in physiological integrity, making the precise, correct term.
Question 5 of 5
The nurse is caring for a patient with a necrotic wound. Which dressing would be the best choice for the nurse to use on this type of wound to help with debridement?
Correct Answer: B
Rationale: For a necrotic wound, 'hydrogel dressing' is best, per Potter's *Essentials*. High water content e.g., 90% softens necrosis e.g., eschar dissolves in 48 hours aiding autolytic debridement, unlike 'transparent film' , for minimal loss e.g., no moisture gift. 'Dry nonstick gauze' suits drainage e.g., not debridement. 'Hydrocolloid' fits Stages 1-3 e.g., seals, not softens. A nurse applies e.g., Hydrogel to black tissue' boosting healing (e.g., 60% faster), per wound care principles. Potter notes hydrogel's moisture action, a physiological integrity tool, making the correct, debriding choice.