ATI LPN
Skin Integrity NCLEX Questions Questions
Question 1 of 5
How will the nurse stage a shallow open reddish, pink ulcer without slough on the right heel?
Correct Answer: B
Rationale: A shallow, reddish-pink ulcer without slough is a Stage II pressure ulcer (Choice B), per NPUAP staging, indicating partial-thickness loss of epidermis/dermis, often appearing as a blister or crater. Stage I is intact skin with redness. Stage III involves deeper fat exposure. Stage IV shows bone or muscle. The heel's description open, shallow, no slough fits Stage II's clinical presentation, requiring moisture-retentive dressings, making this the correct staging for nurses to document and treat appropriately.
Question 2 of 5
What is the next best step for the nurse upon noticing an odor and purulent discharge with increased redness at a healing Stage III pressure ulcer site?
Correct Answer: A
Rationale: Odor, purulent discharge, and redness suggest infection. Completing a full assessment vitals, treatment, labs gathers data for accurate reporting, per the text, before notifying providers. SBAR notification follows assessment. Consulting wound care or the charge nurse is secondary. Comprehensive data collection ensures informed care escalation, making this the correct next step.
Question 3 of 5
Which specialty bed will the nurse use for a patient with a Stage IV pressure ulcer with grafted surgical sites?
Correct Answer: B
Rationale: Air-fluidized beds redistribute pressure via fluid-like immersion, per the text, ideal for Stage IV ulcers with grafts, protecting new tissue. Low-air-loss prevents moisture buildup. Lateral rotation aids pulmonary issues. Standard mattresses lack support. This bed enhances healing, making it the correct choice.
Question 4 of 5
Which nursing diagnosis does the nurse add to the care plan for a patient with a Stage IV pressure ulcer?
Correct Answer: C
Rationale: Stage IV ulcers involve severe skin loss, warranting 'Impaired skin integrity' (Choice C), per NANDA-I, reflecting the primary issue. Enhanced nutrition is a goal, not diagnosis. Mobility and pain may coexist but aren't central. This diagnosis drives wound care, making it the correct addition.
Question 5 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.