ATI LPN
Skin Integrity NCLEX Questions Questions
Question 1 of 5
The need for protective isolation is being explained to the patient who asks, 'How can I hug my children?' An appropriate response would be:
Correct Answer: C
Rationale: Protective isolation shields immunocompromised patients. Explaining microbial risk and immune weakness justifies restrictions, per patient education, fostering understanding. Glass door or intercom are logistics, not reasons. Time reassurance is vague. Clarity on infection risk supports compliance, an LPN role, making it the correct response.
Question 2 of 5
You are caring for a patient with an epidural infusion. Which sign requires immediate provider notification?
Correct Answer: A
Rationale: Epidural analgesia risks hypotension from vasodilation. BP 80/60 signals shock, needing urgent notification, per anesthesia protocols. Temp 99.5°F is mild. Respirations 12/min are normal. Low urine is concerning but slower. Hypotension threatens perfusion, an LPN alert, making it the correct sign.
Question 3 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 4 of 5
Which type of wound healing will the nurse consider when planning care for a patient in the burn unit?
Correct Answer: B
Rationale: Burns, with significant tissue loss, heal by secondary intention (Choice B), per the text, where the wound fills with scar tissue over time, increasing infection risk. Partial-thickness repair is for minor skin loss. Tertiary intention delays closure. Primary intention is for surgical wounds. Secondary intention's prolonged process requires nurses to manage infection and granulation, making this the correct healing type for burn care planning.
Question 5 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.