ATI LPN
Skin Integrity and Wound Care NCLEX Questions Questions
Question 1 of 5
The nurse caring for an unconscious patient who was involved in an automobile accident 2 weeks ago will give priority to which element when planning care to decrease the development of a decubitus ulcer?
Correct Answer: B
Rationale: Pressure is the cornerstone of decubitus ulcer formation, per the flashcards, as sustained force occludes capillaries (15-32 mm Hg), causing tissue ischemia in unconscious patients unable to reposition. Care planning focuses on offloading via turning schedules or specialty beds. Resistance isn't a recognized element here. Weight influences pressure distribution but isn't the root cause. Stress affects general health, not skin integrity directly. Pressure's intensity and duration are modifiable, evidence-based targets nurses prioritize to prevent ulcers, especially in prolonged immobility, making this the correct element.
Question 2 of 5
Which laboratory data will be important for the nurse to monitor when a patient develops a pressure ulcer?
Correct Answer: C
Rationale: Prealbumin , per the flashcards, reflects nutritional status for healing, dropping (<20 mg/dL) in malnutrition a pressure ulcer risk. Vitamin E isn't key. Potassium and sodium are electrolytes, not healing-specific. Nurses track prealbumin over albumin for recent intake, making this the correct data.
Question 3 of 5
The nurse is caring for a patient who has a wound drain with a collection device. The nurse notices that the collection device has a sudden decrease in drainage. Which action will the nurse take initially?
Correct Answer: A
Rationale: A sudden drainage drop suggests blockage. Calling the provider (implied Choice A), per nursing practice, is initial to address patency. Options are missing, but charting or ignoring don't fix it. Nurses escalate promptly, making this the correct initial action.
Question 4 of 5
The nurse is caring for a surgical patient. Which intervention is most important for the nurse to complete to decrease the risk of pressure ulcers and encourage the patient's willingness and ability to increase mobility?
Correct Answer: D
Rationale: Pain hinders mobility, increasing ulcer risk. Analgesics , per the flashcards, enhance willingness and ability to move, reducing pressure. Explaining risks educates. Turning every 3 hours is too infrequent. Sitting helps but lacks pain focus. Pain relief is key, making this the correct intervention.
Question 5 of 5
When caring for a group of patients, which task can the nurse delegate to the nursing assistive personnel (AP)?
Correct Answer: B
Rationale: NAPs handle routine tasks. Applying a gauze bandage , per the flashcards, is within their scope, securing dressings safely. Assessing risk , treating ulcers , and negative-pressure therapy require RN judgment. This delegation is appropriate, making it the correct task.