ATI LPN
Skin Integrity and Wound Care NCLEX Questions Questions
Question 1 of 5
In determining the patient's perception of pain, which question would be useful?
Correct Answer: C
Rationale: Pain perception is subjective.'How would you describe your pain?' captures quality (e.g., sharp), per PQRST assessment, guiding care. Location and history inform but don't define perception. Activity is context, not feeling. Description shapes treatment, an LPN tool, making it the correct question.
Question 2 of 5
Which nursing observation will indicate the patient is at risk for pressure ulcer formation?
Correct Answer: A
Rationale: Fecal incontinence increases pressure ulcer risk by exposing skin to moisture, bacteria, and enzymes, causing maceration and breakdown, per nursing principles. Eating two-thirds of breakfast suggests some nutrition, not a risk indicator. A red rash on the shin is concerning but not a high-risk pressure area like the sacrum or heels. Normal capillary refill indicates good circulation, not risk. Moisture from incontinence softens skin, amplifying pressure effects, making this the key observation nurses note for early intervention, aligning with risk assessment tools like Braden.
Question 3 of 5
Which type of tissue will the nurse expect to observe when a wound is healing by full-thickness repair?
Correct Answer: C
Rationale: Full-thickness repair, as in Stage IV ulcers, progresses with granulation tissue red, moist, vascular tissue signaling healing, per the text. Eschar is necrotic, blocking healing. Slough is dead tissue needing removal. Purulent drainage indicates infection, not progress. Granulation marks the proliferative phase, a positive sign nurses monitor, guiding dressing choices like hydrogels, making this the correct tissue expected in healing.
Question 4 of 5
Which laboratory data will be important for the nurse to check for a patient who has developed a pressure ulcer?
Correct Answer: C
Rationale: Albumin reflects nutritional status critical for wound healing, per the text, with low levels (<3.5 g/dL) indicating malnutrition a pressure ulcer risk. Vitamin E isn't key. Potassium and sodium affect electrolytes, not healing directly. Nurses monitor albumin (and prealbumin) to ensure protein supports tissue repair, making this the correct lab data to check.
Question 5 of 5
Which action should the nurse take first when changing a dressing on a wound with a drain?
Correct Answer: A
Rationale: Dressing changes cause pain. Providing analgesics 30 minutes prior (Choice A), per the text, eases discomfort, enhancing patient cooperation. Avoiding drain removal and gloves follow. Gathering supplies is preparatory. Pain management sets the stage for a smooth procedure, making this the correct first action.