ATI LPN
Skin Integrity and Wound Care NCLEX Questions Questions
Question 1 of 5
Before you administer an opioid analgesic, the most important nursing action is to:
Correct Answer: D
Rationale: Opioids risk respiratory depression. Assessing respirations ensures safety rate <12/min signals danger, per pharmacology. BP is secondary. Comfort measures delay meds. Constipation is later. Breathing is the priority, an LPN check, making it the correct action.
Question 2 of 5
Which type of tissue will the nurse expect to observe when a wound is healing by full-thickness repair?
Correct Answer: C
Rationale: Full-thickness repair, as in Stage IV ulcers, progresses with granulation tissue red, moist, vascular tissue signaling healing, per the text. Eschar is necrotic, blocking healing. Slough is dead tissue needing removal. Purulent drainage indicates infection, not progress. Granulation marks the proliferative phase, a positive sign nurses monitor, guiding dressing choices like hydrogels, making this the correct tissue expected in healing.
Question 3 of 5
Which laboratory data will be important for the nurse to check for a patient who has developed a pressure ulcer?
Correct Answer: C
Rationale: Albumin reflects nutritional status critical for wound healing, per the text, with low levels (<3.5 g/dL) indicating malnutrition a pressure ulcer risk. Vitamin E isn't key. Potassium and sodium affect electrolytes, not healing directly. Nurses monitor albumin (and prealbumin) to ensure protein supports tissue repair, making this the correct lab data to check.
Question 4 of 5
Which action should the nurse take first when changing a dressing on a wound with a drain?
Correct Answer: A
Rationale: Dressing changes cause pain. Providing analgesics 30 minutes prior (Choice A), per the text, eases discomfort, enhancing patient cooperation. Avoiding drain removal and gloves follow. Gathering supplies is preparatory. Pain management sets the stage for a smooth procedure, making this the correct first action.
Question 5 of 5
Which score will the nurse document for a patient with slight sensory impairment, rarely moist skin, occasional walking, slightly limited mobility, excellent meal intake, and no friction/shear issues using the Braden Scale?
Correct Answer: C
Rationale: Braden Scale scores (6-23) assess risk; lower means higher risk. Per the text: slight sensory impairment (3), rarely moist (4), walks occasionally (3), slightly limited mobility (3), excellent intake (4), no friction/shear (4) total 20 (Choice C). This reflects moderate risk, making it the correct score.