ATI RN
Skin Integrity NCLEX Questions Questions
Question 1 of 5
A nurse working in long-term care is assessing residents at risk for the development of a decubitus ulcer. Which one would be most at risk?
Correct Answer: D
Rationale: An 86-year-old who is bedfast' is most at risk. Immobility e.g., 24/7 presses e.g., 32 mmHg causing ulcers e.g., 70% odds unlike 'mobile 83-year-old' , low e.g., 10%. 'Walker' and 'cane' aid e.g., 20-30%. A nurse assesses e.g., Bedfast, high risk' per Braden, a physiological red flag. The text links immobility to ulcers, making the correct, highest-risk resident.
Question 2 of 5
How would the nurse measure the length of the time the redness lasts, which assessment measure should the nurse perform?
Correct Answer: A
Rationale: The correct answer is A: Apply light pressure to the area with the fingertips. By applying light pressure, the nurse can assess the blanching response, which helps determine how long the redness lasts. This method helps evaluate the skin's perfusion and the duration of capillary refill time. Summary: B: Observing for wound approximation is not related to measuring the duration of redness. C: Obtaining a wound culture is unrelated to assessing the length of redness duration. D: Gently lifting a fold of skin does not provide information on the duration of redness.
Question 3 of 5
What documentation should be included in a wound assessment?
Correct Answer: A
Rationale: The correct answer is A because it includes essential elements for a comprehensive wound assessment. Redness indicates inflammation, edema shows swelling, ecchymosis indicates bleeding, drainage helps assess infection, approximation evaluates wound closure, and location provides contextual information. Choice B, reactive hyperemia, is not a standard component of wound assessment. Choice C, unusual skin mottling, is vague and not specific to wound assessment. Choice D, excessive pallor, is more related to skin color changes and may not always be relevant in wound assessment. Overall, choice A covers a wide range of key factors necessary for a thorough evaluation of a wound.
Question 4 of 5
It is most important to include this group in which aspect of Aaron's overall care?
Correct Answer: B
Rationale: The correct answer is B because planning meals to promote wound healing directly impacts Aaron's physical well-being and recovery. Proper nutrition plays a crucial role in wound healing. Reviewing class notes and studying for exams (A) is important but not as critical to his immediate health. Purchasing wound care supplies (C) is necessary but doesn't address the root cause of the issue. Reminiscing about the past (D) is irrelevant to Aaron's current care needs. In summary, option B focuses on a key aspect of Aaron's care by addressing his physical health and promoting recovery.
Question 5 of 5
The nurse is teaching a child care class for mothers of young children. What should the nurse teach as being the most common mode of transmission of infectious disease?
Correct Answer: D
Rationale: The correct answer is D because not washing hands after using the bathroom is the most common way for infectious diseases to spread due to contact with fecal matter containing harmful pathogens. This practice can lead to contamination of surfaces, food, and direct contact with others. Choices A, B, and C involve close contact activities but do not directly involve the transfer of pathogens as significantly as improper hand hygiene. Option A and B may involve some contact, but the level of exposure to pathogens is lower compared to not washing hands after using the bathroom. Option C involves sharing toys, which can spread germs, but it is not as common as the direct transmission through unwashed hands.