ATI LPN
NCLEX Questions Skin Integrity and Wound Care Questions
Question 1 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 2 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.
Question 3 of 5
A client has an arterial ulcer on the left lower leg. The nurse observes that the ulcer has a pale pink base, minimal drainage, and no signs of infection. What is an appropriate dressing for this ulcer?
Correct Answer: D
Rationale: Hydrogel dressing is the correct answer for an arterial ulcer with a pale pink base, minimal drainage, and no infection. Arterial ulcers, caused by poor blood flow, often present as dry or minimally exudative wounds, and hydrogel provides essential moisture to rehydrate the wound bed, promoting autolytic debridement and healing. Its water- or glycerin-based composition suits this scenario, preventing desiccation while supporting tissue regeneration. Transparent film offers protection but lacks moisture donation, making it better for superficial, dry wounds, not arterial ulcers needing hydration. Calcium alginate is highly absorbent, ideal for heavy exudate, not minimal drainage, and could dry out this wound further. Silver-impregnated dressing targets infection, unnecessary here without signs of bacterial involvement. Hydrogel's hydrating properties align perfectly with the ulcer's characteristics, fostering an optimal healing environment without overwhelming the wound or surrounding skin.
Question 4 of 5
A client is receiving negative pressure wound therapy (NPWT) for a diabetic foot ulcer. Which action should the nurse take when changing the dressing?
Correct Answer: A
Rationale: Applying sterile saline to moisten the foam dressing before removal is the correct action during an NPWT dressing change for a diabetic foot ulcer. The foam can adhere to the wound bed, and moistening it with saline prevents trauma, pain, or bleeding upon removal, protecting fragile granulation tissue common in diabetic wounds. Cutting the foam loosely is incorrect; it should fit snugly to ensure even pressure distribution. Securing the film with tape risks air leaks; an adhesive drape extending beyond the edges is standard to maintain the seal. Disconnecting tubing from the foam first disrupts suction prematurely; it should detach from the device first to avoid pressure issues. Moistening with saline is a precise, evidence-based step to safeguard the wound, especially critical in diabetic patients with impaired healing.
Question 5 of 5
A client is admitted to the hospital with a diabetic foot ulcer. The nurse notes that the wound has black, dry, and hard tissue covering most of the wound bed. How should the nurse document this finding?
Correct Answer: A
Rationale: Eschar is the correct documentation for black, dry, and hard tissue covering a diabetic foot ulcer's wound bed. Eschar is necrotic tissue that's firm and adherent, often stable (dry, intact) or unstable (moist, loose), and in diabetic wounds, it delays healing and risks infection, requiring accurate identification. Slough is softer, moist, and typically yellow or green, not matching the dry, hard description. Fibrin is a yellowish clotting protein, not black or extensive like eschar. Exudate is fluid, not tissue, and doesn't fit. Eschar's distinct characteristics color, texture, and dryness differentiate it, and proper documentation guides treatment, like debridement, critical for diabetic wound management to prevent complications like osteomyelitis.