ATI LPN
Skin Integrity and Wound Care NCLEX Questions Quizlet Questions
Question 1 of 5
How should the nurse document a healing Stage III pressure ulcer with healthy tissue observed?
Correct Answer: C
Rationale: A Stage III pressure ulcer involves full-thickness skin loss with visible fat. When healing with healthy tissue, it's documented as 'Healing Stage III' (Choice C), per staging guidelines, retaining its original stage while noting progress. Stage I is nonblanchable redness, not applicable. Healing Stage II implies partial-thickness, underrepresenting depth. Stage III without 'healing' ignores improvement. Accurate documentation reflects the wound's history and current state, aiding care continuity and reimbursement, making 'Healing Stage III' the correct choice for this scenario.
Question 2 of 5
Which assessment data will be most important for the nurse to gather with regard to wound healing?
Correct Answer: B
Rationale: Pulse oximetry measures oxygen saturation, vital for wound healing, per the text, as oxygen fuels cellular repair. Muscular strength and sensation assess mobility and nerve function, not healing directly. Sleep aids recovery but isn't specific. Adequate oxygenation (e.g., >90%) prevents hypoxia-related delays, making this the correct priority data for nurses to gather.
Question 3 of 5
Which action will the nurse take next if a wound drain's collection device shows a sudden decrease in drainage?
Correct Answer: A
Rationale: A sudden drainage drop suggests blockage (Choice A), per the text, requiring provider notification for intervention. Charting delays action. Compression doesn't confirm patency. Nurses don't remove drains (Choice D). Prompt reporting prevents complications like fluid buildup, making this the correct next step.
Question 4 of 5
Which intervention is most important to decrease the risk of pressure ulcers and encourage the patient's willingness and ability to increase mobility?
Correct Answer: D
Rationale: Pain limits mobility, increasing ulcer risk. Analgesics (Choice D), per the text, boost willingness and ability to move, reducing pressure. Explaining risks educates but doesn't enable. Turning every 3 hours is too infrequent (2 hours is standard). Sitting helps but lacks pain focus. Pain relief is key, making this the correct intervention.
Question 5 of 5
Which initial action should the nurse take to decrease the risk of skin impairment for a patient with residual mobility problems after a stroke?
Correct Answer: A
Rationale: Skin integrity begins with basic care. Using gentle cleansers and thorough drying (Choice A), reduces irritation and moisture key risks for a stroke patient with limited mobility. Harsh soaps disrupt skin barriers, and wet skin fosters maceration, both accelerating breakdown over bony prominences. Therapeutic beds help but are secondary, addressing pressure after skin protection. Absorbent pads are controversial, used only if other options fail, as they may trap moisture. Products holding moisture worsen risk, opposite to prevention goals. Gentle cleansing and drying are foundational, proactive steps nurses take first to maintain skin health, aligning with evidence-based practice and making this the correct initial action.