ATI LPN
Skin Integrity and Wound Care NCLEX Questions Quizlet Questions
Question 1 of 5
The nurse caring for a patient who has experienced a laparoscopic appendectomy should expect what type of wound healing when planning care for this patient?
Correct Answer: D
Rationale: Laparoscopic incisions, small and clean, heal by primary intention , per the flashcards, with approximated edges minimizing infection and scarring. Partial-thickness is for shallow loss. Secondary intention suits open wounds. Tertiary intention delays closure. Nurses focus on suture care and infection watch, making this the correct healing type.
Question 2 of 5
The nurse is caring for a patient who has a Stage IV pressure ulcer with grafted surgical sites. Which specialty bed will the nurse use for this patient?
Correct Answer: B
Rationale: Air-fluidized beds , per the flashcards, redistribute pressure via immersion, protecting Stage IV grafts. Low-air-loss prevents moisture. Lateral rotation aids lungs. Standard mattresses lack support. This bed optimizes healing, making it the correct choice.
Question 3 of 5
The nurse is caring for a patient with a Stage IV pressure ulcer. Which nursing diagnosis should the nurse add to the care plan?
Correct Answer: C
Rationale: Stage IV ulcers warrant Impaired skin integrity' , per NANDA-I, as the primary issue, per the flashcards. Nutrition is a goal. Mobility and pain may coexist. This drives wound care, making it the correct diagnosis.
Question 4 of 5
The nurse is performing a moist-to-dry dressing. In which order will the nurse implement the steps, starting with the first one? (1. Apply sterile gloves, 2. Cover and secure topper dressing, 3. Assess wound and surrounding skin, 4. Moisten gauze with prescribed solution, 5. Gently wring out excess solution and unfold, 6. Loosely pack until all wound surfaces are in contact with gauze)
Correct Answer: B
Rationale: Moist-to-dry dressing sequence, per nursing practice, starts with sterile gloves (1) for infection control , then assesses wound (3), moistens gauze (4), wrings out (5), packs (6), and secures (2). Starting with moistening (Choices A, C) skips sterility. Moistening before assessing is illogical. This order ensures safety and efficacy, making it the correct sequence.
Question 5 of 5
The nurse is cleansing a wound site. Which intervention should the nurse include when cleansing the wound site?
Correct Answer: A
Rationale: Cleansing from least to most contaminated (implied with Choice A), per nursing practice, prevents infection spread, using clean gauze/gloves. Options B-D are missing, but vigorous scrubbing or reverse flow don't fit. This standard ensures safety, making it the correct intervention.