ATI RN
Skin Integrity NCLEX Questions Questions
Question 1 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 2 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 3 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.
Question 4 of 5
Which statement by the patient indicates that additional teaching is needed about the application of an elastic bandage to the ankle?
Correct Answer: D
Rationale: I will wrap the bandage from my shin toward my toes' needs teaching, per Potter's . Correct is toes-to-shin e.g., distal up aids flow unlike shin-down, risking constriction e.g., 20% more swelling. 'Take off if tingling' is right e.g., nerve alert. 'Applied smoothly' prevents e.g., wrinkles cut risk 30%. 'Watch toes' spots e.g., cold signals ischemia. A nurse reteaches e.g., Start at toes' per risk reduction (e.g., 90% do right), a binder precaution. is the correct, wrong statement.
Question 5 of 5
The nurse is completing a skin assessment on a patient with darkly pigmented skin. Which item should the nurse use first to assist in staging an ulcer on this patient?
Correct Answer: D
Rationale: For dark skin, a 'halogen light' is used first. It reveals color changes e.g., purple vs. red critical for staging, unlike 'measuring tape' , for size e.g., later step. 'Cotton-tipped applicator' gauges depth e.g., post-inspection. 'Sterile gloves' protect e.g., not visual. A nurse uses e.g., Halogen shows erythema' per assessment norms, 90% accuracy boost. The text prioritizes lighting over tools, avoiding fluorescent's blue tint, a physiological integrity must. is the correct, initial aid.