ATI LPN
Skin Integrity NCLEX Questions Questions
Question 1 of 5
How long should the nurse schedule a patient at risk for skin impairment to sit in a chair?
Correct Answer: B
Rationale: Prolonged sitting increases pressure on ischial tuberosities, risking skin breakdown. Scheduling less than 2 hours (Choice B), per the text, limits ischemia, especially for at-risk patients, balancing mobility with safety. Over 3 hours exceeds safe pressure duration, per studies showing tissue damage after 2 hours. Thirty minutes is overly restrictive, reducing mobility benefits. Comfort-based duration ignores objective risk, as patients may not feel early damage. The 2-hour limit, often with cushions, is a standard nursing intervention to redistribute pressure, making this the correct choice for protecting skin integrity.
Question 2 of 5
The nurse is caring for a postoperative patient who has had abdominal surgery and whose wound has completely eviscerated when the nurse walks into the room. In addition to notifying the surgeon, what should the nurse do?
Correct Answer: D
Rationale: Moist saline gauze prevents drying and further damage in evisceration until surgical intervention.
Question 3 of 5
The nurse knows that a hydrocolloid dressing is appropriate for use on which type of wound?
Correct Answer: D
Rationale: Hydrocolloids absorb moderate drainage and form a gel, unsuitable for heavy drainage or tunneling.
Question 4 of 5
The nurse knows what goal to be appropriate for a patient with a stage 3 pressure ulcer with the nursing diagnosis impaired physical mobility?
Correct Answer: C
Rationale: Assisting with position changes addresses impaired mobility directly.
Question 5 of 5
The wound care nurse is monitoring a patient with a Stage III pressure ulcer whose wound presents with healthy tissue. How should the nurse document this ulcer in the patient's medical record?
Correct Answer: C
Rationale: A Stage III ulcer, with full-thickness loss to fat, retains its stage even as it heals. Healing Stage III' , per the flashcards, reflects healthy tissue (e.g., granulation) while preserving original staging for accuracy and care continuity. Stage I is intact skin, not applicable. Healing Stage II underestimates depth. Stage III alone omits healing progress. Proper documentation, per NPUAP guidelines, informs treatment (e.g., moist dressings) and reimbursement, making this the correct choice for nurses.