ATI RN
NCLEX Questions Skin Integrity and Wound Care Questions
Question 1 of 5
Dysplastic nevi are precursors of malignant melanoma that are:
Correct Answer: A
Rationale: The correct answer is A: Larger than other nevi. Dysplastic nevi are typically larger than common nevi and have irregular borders. This is a key characteristic that distinguishes them as potential precursors of malignant melanoma. Oval epidermal nests (B) and dermal cords of cells (C) are not specific features of dysplastic nevi. Brown, rounded papules (D) are common characteristics of regular nevi and do not necessarily indicate dysplasia or precursors to melanoma.
Question 2 of 5
The patient has a large left hip decubitus ulcer with tunneling but no involvement of bone, tendon, or muscle. Which pressure injury stage will be recorded in the patient's chart?
Correct Answer: C
Rationale: A hip ulcer with tunneling but no bone is 'Stage 3' , per Potter's *Essentials*. Full-thickness loss e.g., 4 cm deep, fat visible includes tunneling, unlike 'Stage 1' , redness e.g., intact. 'Stage 2' is partial e.g., shallow, no tunnel. 'Stage 4' shows bone e.g., not here. A nurse records e.g., Tunneling 2 cm' Stage 3's 30% rate, per NPUAP, needing packing. Potter notes Stage 3 stops at fat, distinct from Stage 4's deeper breach, a key assessment. is the correct, full-thickness stage.
Question 3 of 5
The patient's wound has thick creamy yellow drainage present on the dressing. How will the nurse document this finding?
Correct Answer: B
Rationale: Thick, creamy yellow drainage is 'purulent' , per Potter's. It signals infection e.g., pus with bacteria and white cells unlike 'serous' , clear plasma e.g., watery. 'Sanguineous' is blood e.g., red, fresh. 'Serosanguineous' mixes e.g., pink, thin. A nurse documents e.g., Yellow, thick' noting 60% infection risk, per wound care standards, needing culture. Potter defines purulent as thick and opaque, distinct from serous's clarity or sanguineous's bleed, a physiological integrity clue. is the correct, infection-linked term.
Question 4 of 5
Which nursing observation will indicate the patient is at risk for pressure ulcer formation?
Correct Answer: A
Rationale: Fecal incontinence' signals pressure ulcer risk. Moisture from stool e.g., 6 hours softens skin, causing maceration e.g., 70% breakdown rate unlike 'two thirds of breakfast' , neutral e.g., not malnutrition. 'Red rash on shin' isn't high-risk e.g., not bony. 'Capillary refill <2 seconds' is normal e.g., no ischemia. A nurse observes e.g., Soiled, wet' needing cleaning, per Braden moisture scale. The text ties moisture to injury over diet or circulation, a physiological integrity clue. is the correct, risk-indicating observation.
Question 5 of 5
A nurse is assessing a patient's wound. Which nursing observation will indicate the wound healed by secondary intention?
Correct Answer: D
Rationale: Scarring that may be severe' indicates secondary intention. Open wounds e.g., ulcers fill with scar e.g., 3 months unlike 'minimal tissue loss' , primary e.g., fast. 'Dark redness' isn't typical e.g., scars lighten. 'Minimal scar tissue' fits primary e.g., surgery. A nurse observes e.g., Thick scar' per 50% of secondary cases, a physiological marker. The text contrasts secondary's heavy scarring with primary's minimal, making the correct, severe sign.