ATI LPN
Skin Integrity and Wound Care NCLEX Questions Questions
Question 1 of 5
By which group is the use of HCAHPS mandated?
Correct Answer: B
Rationale: HCAHPS is a federal mandate. CMS , per the test, requires it since 2006 for Medicare hospitals, linking scores to payment. Boards or states may encourage. ACGME focuses on education. CMS enforcement ensures standardized patient experience data, making it the correct group.
Question 2 of 5
The nurse is monitoring a wound in a dark-skinned client for signs of erythema. How would the nurse best determine the presence of erythema?
Correct Answer: D
Rationale: Erythema in dark skin isn't always red. Palpating for increased temperature , per wound assessment texts (e.g., Potter & Perry), detects inflammation reliably, as color changes may appear ashen or purple. Drainage indicates infection, not erythema. Swelling is secondary. Dark skin requires tactile cues over visual, ensuring accurate monitoring for complications like infection, making this the best method.
Question 3 of 5
A client is recovering and the nurse would encourage the client to eat which food item that is naturally high in vitamin C to promote wound healing?
Correct Answer: B
Rationale: Vitamin C aids collagen. Oranges , per nutrition science, are high in vitamin C (~70mg/fruit), boosting wound repair. Milk offers protein, not C. Bananas provide potassium. Chicken supports protein, not C. Encouraging citrus enhances healing, per dietary guidelines, making this the correct food.
Question 4 of 5
A nurse is applying a dressing to a wound that has moderate to heavy exudate. Which of the following types of dressing would be most appropriate for this wound?
Correct Answer: D
Rationale: Alginate is the correct answer because it is highly absorbent, capable of managing moderate to heavy exudate by absorbing up to 20 times its weight in fluid, making it ideal for such wounds. It forms a gel when in contact with exudate, maintaining a moist environment that supports healing and autolytic debridement, while preventing maceration of surrounding skin. Transparent film is non-absorbent and suited for dry wounds, offering protection but not fluid management. Hydrogel is minimally absorbent and better for dry or minimally exudative wounds, providing hydration rather than absorption. Foam is moderately absorbent, handling light to moderate exudate, but less effective than alginate for heavy drainage due to its lower capacity (up to four times its weight). The wound's moderate to heavy exudate requires a dressing like alginate to effectively manage fluid and promote optimal healing conditions.
Question 5 of 5
A client is admitted to the hospital with a burn injury covering $30% of the body surface area. The nurse anticipates that the client will require which type of dressing for wound care?
Correct Answer: D
Rationale: Silver dressing is the correct answer because it's ideal for burn injuries covering 30% of the body surface area due to its antimicrobial properties, reducing infection risk a major concern in burns where skin barriers are compromised. Silver ions kill bacteria, manage pain, inflammation, and odor, supporting healing in high-risk wounds. Hydrocolloid dressing is occlusive, suited for minimal-drainage wounds, but can trap bacteria in infected or heavily exudative burns, risking maceration. Hydrogel dressing hydrates dry wounds but lacks sufficient absorption for burn exudate and isn't antimicrobial, making it less suitable. Alginate dressing absorbs heavy exudate but isn't ideal for dry or minimally draining burns and lacks inherent infection control. Given the burn's extent and infection vulnerability, silver dressing offers the best protective and therapeutic benefits.