ATI LPN
NCLEX Practice Questions Skin Integrity and Wound Care Questions
Question 1 of 5
Examples of computer based decision support include all except:
Correct Answer: D
Rationale: Decision support guides, doesn't enforce. Linking orders to indications , per the test, lacks active guidance (e.g., suggestions), unlike alerts , reminders , or order sets , per HIMSS definitions. It's a rule, not support. True decision support aids clinical judgment, making this the correct exception.
Question 2 of 5
A client arriving at the emergency department has experienced frostbite to the right hand. Which finding would the nurse note on assessment of the client's hand?
Correct Answer: D
Rationale: Frostbite shows tissue freezing. White, insensitive skin , per emergency nursing texts, indicates early frostbite (stage 1), with vasoconstriction and numbness. Pink edema suggests rewarming. Red skin or black tips reflect later stages (thawing or necrosis). Initial assessment notes pallor and sensory loss, guiding rewarming care, making this the correct finding.
Question 3 of 5
A nurse is caring for a client who has a surgical incision with sutures. The nurse observes that the edges of the wound are well approximated and there is minimal drainage from the site. The nurse documents this type of wound healing as:
Correct Answer: A
Rationale: Primary intention is the correct answer as it describes wound healing where the edges are well approximated, such as with sutures, and there's minimal tissue loss or drainage, leading to fast healing with minimal scarring. This typically occurs in clean, surgical incisions where the body can efficiently close the wound through epithelialization. Secondary intention occurs when wound edges are not approximated, often due to significant tissue loss or infection, healing through granulation tissue formation, which takes longer and results in more scarring. Tertiary intention involves a delay in closure, often intentionally left open for drainage or debridement before suturing, resulting in intermediate scarring. Quaternary intention is not a recognized term in wound healing classifications. The scenario's description of well-approximated edges and minimal drainage aligns with primary intention, reflecting an optimal healing process under controlled conditions.
Question 4 of 5
A client with a surgical wound on the abdomen has a negative pressure wound therapy (NPWT) device attached to the wound. Which action should the nurse take when caring for this client?
Correct Answer: C
Rationale: Choice C is correct because ensuring the dressing is sealed and airtight around the wound is essential for effective negative pressure wound therapy (NPWT). NPWT relies on consistent subatmospheric pressure to promote healing by removing fluid, reducing edema, and stimulating granulation tissue, which requires an airtight seal to maintain suction. Changing the dressing every 12 hours is too frequent; NPWT dressings are typically changed every 48-72 hours unless specified otherwise, as frequent changes disrupt healing. Irrigating with saline before dressing risks introducing bacteria and interrupting pressure, countering NPWT's purpose cleaning should occur prior, not during application. Clamping the tubing during movement disrupts pressure and risks tissue damage; securing it to avoid kinking is preferred. An airtight seal ensures NPWT's therapeutic benefits, making it the priority action.
Question 5 of 5
A nurse is caring for a client who has undergone a skin graft to cover a burn injury on the right arm. Which intervention should the nurse include in the plan of care to promote graft adherence?
Correct Answer: C
Rationale: Immobilizing the right arm with a splint or sling is the correct answer, as it promotes graft adherence by preventing movement and shear forces that could dislodge the newly placed skin graft. Stability is critical in the initial days post-grafting to allow the graft to establish blood supply from the wound bed, ensuring survival and integration. Elevation may reduce edema but isn't the primary intervention for adherence, though it can aid comfort and swelling control. Applying negative pressure wound therapy is contraindicated for grafts, as suction could disrupt fragile tissue, cause bleeding, or lift the graft, undermining its purpose. Irrigation with saline twice daily risks disturbing the graft's attachment and introduces infection risk, countering sterile post-op protocols that favor minimal interference. Immobilization directly addresses the mechanical stability needed for graft take, making it the most effective nursing action in this scenario, supported by standard wound care principles.