ATI LPN
NCLEX Questions Skin Integrity and Wound Care Questions
Question 1 of 5
Patient-Centeredness is best defined as:
Correct Answer: B
Rationale: Patient-centeredness prioritizes individuality. Respecting preferences, needs, and values , per the test and Picker Institute, defines it, integrating emotional and cultural care. Patient-only decisions lack guidance. Evidence-based care is quality, not centeredness. Holistic focus is narrower. This definition drives HCAHPS metrics, making it the correct choice.
Question 2 of 5
The nurse is assessing the perineal wound in a client who has returned from the operating room following an abdominal perineal resection and notes serosanguineous drainage from the wound. Which nursing intervention is most appropriate?
Correct Answer: C
Rationale: Serosanguineous drainage is normal post-op. Changing the dressing as prescribed aligns with wound care standards (e.g., ATI Nursing), managing expected drainage (pink, watery fluid) without escalation. Notifying the surgeon is premature unless excessive. Clamping risks fluid buildup, potentially causing infection. Removing packing disrupts healing unless ordered. Perineal resection wounds typically drain initially; routine dressing changes maintain cleanliness and monitor progress, making this the most appropriate intervention per evidence-based practice.
Question 3 of 5
The evening nurse reviews the nursing documentation in a client's chart and notes that the day nurse has documented that the client has a stage II pressure ulcer in the sacral area. Which finding would the nurse expect to note on assessment of the client's sacral area?
Correct Answer: D
Rationale: Stage II ulcers are partial. Partial-thickness loss , per NPUAP staging, shows blisters or shallow craters, matching documentation. Intact skin is stage 1. Full-thickness or exposed tissue are stages III-IV. The nurse expects dermis-level damage, guiding dressing choice, making this the correct finding.
Question 4 of 5
A client has a wound on the lower leg that is covered with dry, yellow crusts. The nurse recognizes this as an indication of:
Correct Answer: A
Rationale: Slough is the correct answer, as it refers to dead tissue that appears as dry, yellow crusts on a wound's surface, indicating tissue that needs removal to promote healing. Slough can vary in color (white, yellow, green, or brown) and texture (soft, moist, or dry), and its presence suggests the wound is not fully progressing toward recovery without intervention like debridement. Eschar is also dead tissue but is typically black, brown, or tan, with a hard, leathery texture, often serving as a natural barrier in some cases but potentially impeding healing in others. Granulation tissue is healthy, new tissue that appears red or pink, shiny, and moist, signaling active healing, not crusting. Epithelial tissue is the thin, smooth layer forming over granulation tissue in the final healing stages, not matching the dry, yellow description. The dry, yellow crusts clearly point to slough, distinguishing it from the other options based on appearance and role in wound progression.
Question 5 of 5
A nurse is assessing a client with a pressure ulcer on the sacrum. Which finding indicates a potential complication of the wound?
Correct Answer: C
Rationale: Foul odor from the wound is the correct answer, as it suggests a potential complication like infection or necrotic tissue, which can impede healing and lead to serious issues like sepsis. Serous drainage is normal, consisting of clear, watery fluid from capillaries, and doesn't inherently signal trouble unless excessive or cloudy. Erythema around the wound edges is expected during healing, reflecting increased blood flow and inflammation, not necessarily a complication unless it worsens or spreads. Granulation tissue in the wound bed is a positive sign of healing, indicating new tissue growth, not a problem. Foul odor, however, often accompanies bacterial overgrowth or dead tissue breakdown, requiring immediate assessment, possibly a culture, and intervention to prevent escalation, distinguishing it as a red flag among these findings.