ATI RN
Skin Integrity and Wound Care NCLEX Questions Questions
Question 1 of 5
How will the nurse obtain a culture of the patient's wound?
Correct Answer: D
Rationale: To culture a wound, 'gently swab the center after irrigating with sterile saline' is correct, per Potter's *Essentials*. Irrigation e.g., 10 mL saline cleans debris, ensuring accurate swab e.g., 90% pathogen catch unlike 'drainage bag' , contaminated e.g., old fluid. 'Edge' misses e.g., surface bacteria, not core. 'Dressing' taints e.g., external bugs. A nurse swabs e.g., Clean center' per infection control (e.g., CLSI standards), a safety must. Potter stresses sterile technique, making the correct, precise method.
Question 2 of 5
The nurse is caring for a patient who has experienced a total abdominal hysterectomy. Which nursing observation of the incision will indicate the patient is experiencing a complication of wound healing?
Correct Answer: D
Rationale: A 'bluish mass' signals a hematoma, a healing complication. Blood under tissue e.g., 50 mL shows swelling e.g., 2 cm unlike 'hurting' , normal e.g., nerve trauma. 'Approximated' is healing e.g., edges shut. 'Itching' is progress e.g., regeneration. A nurse notes e.g., Blue lump' per 10% post-op risk, needing monitoring. The text flags hematoma's vascular threat, making the correct, alarming observation.
Question 3 of 5
The nurse is caring for a patient who has a wound drain with a collection device. The nurse notices that the collection device has a sudden decrease in drainage. Which action will the nurse take next?
Correct Answer: A
Rationale: A sudden drainage drop prompts 'call the health care provider' . Blockage e.g., clot in tube needs fix e.g., 20% risk unlike 'charting' , passive e.g., delays care. 'Do nothing' risks e.g., compression hides issue. 'Remove drain' is MD's call e.g., not nurse. A nurse acts e.g., No flow, call' per patency rules, a physiological need. The text flags sudden stops, making the correct, proactive step.
Question 4 of 5
The nurse is caring for a patient who is immobile. The nurse wants to decrease the formation of pressure ulcers. Which action will the nurse take first?
Correct Answer: C
Rationale: Determine the patient's risk factors' is first. Assessing e.g., Braden score guides prevention e.g., 16 flags 50% risk unlike 'fluids' , secondary e.g., hydration. 'Turn q2h' follows e.g., intervention. 'Carbs/fats' is vague e.g., not priority. A nurse starts e.g., Check mobility' per protocol, a physiological must. The text mandates risk first, making the correct, initial action.
Question 5 of 5
The nurse is caring for a patient with a wound. The patient appears anxious as the nurse is preparing to change the dressing. Which action should the nurse take?
Correct Answer: B
Rationale: Explain the procedure' reduces anxiety. Educating e.g., I'll clean, cover' empowers e.g., 70% less fear unlike 'television' , distraction e.g., not control. 'Close your eyes' avoids e.g., no engagement. 'Ask family to leave' may worsen e.g., support lost. A nurse says e.g., Here's what's next' per psychosocial care, a comfort must. The text ties explanation to calm, making the correct, supportive action.