ATI RN
Skin Integrity and Wound Care NCLEX Questions Quizlet Questions
Question 1 of 5
The nurse is admitting an older patient from a nursing home. During the assessment, the nurse notes a shallow open reddish, pink ulcer without slough on the right heel of the patient. How will the nurse stage this pressure ulcer?
Correct Answer: B
Rationale: A shallow, reddish-pink heel ulcer without slough is 'Stage II' Partial-thickness e.g., dermis exposed, 2 mm deep fits, unlike 'Stage I' , nonblanchable redness e.g., intact. 'Stage III' is full-thickness e.g., fat, not here. 'Stage IV' shows bone e.g., deeper. A nurse stages e.g., Open, pink' per NPUAP, 40% of heel ulcers, needing dressing. The text defines Stage II as shallow, distinct from Stage I's surface, a physiological integrity call. is the correct, dermal stage.
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: For Stage IV with grafts, an 'air-fluidized' bed is best. Fluid-like support e.g., air through beads redistributes pressure e.g., <15 mmHg unlike 'low-air-loss' , moisture control e.g., not graft-specific. 'Lateral rotation' aids lungs e.g., not skin. 'Standard mattress' risks e.g., 32 mmHg. A nurse uses e.g., Air-fluidized for grafts' per 70% graft success, a physiological must. The text specifies this for surgical sites, making the correct, optimal bed.
Question 3 of 5
The medical-surgical acute care patient has received a nursing diagnosis of Impaired skin integrity. Which health care team member will the nurse consult?
Correct Answer: B
Rationale: The nurse consults a 'registered dietitian' for impaired skin integrity. Nutrition e.g., protein 1.5 g/kg speeds healing e.g., 40% faster unlike 'respiratory therapist' , lungs e.g., not skin. 'Case manager' plans discharge e.g., not nutrition. 'Chaplain' aids spirit e.g., not physical. A nurse calls e.g., Diet consult' per team care, a physiological need. The text ties diet to repair, making the correct, expert choice.
Question 4 of 5
The nurse is cleansing a wound site. As the nurse administers the procedure, which intervention should be included?
Correct Answer: C
Rationale: Cleanse in a direction from the least contaminated area' is key. Moving outward e.g., wound to skin limits spread e.g., 90% safer unlike 'most to least' , reverse e.g., contaminates. 'Scrub vigorously' harms e.g., tissue damage. 'Clean gauze/gloves' is prep e.g., not direction. A nurse cleans e.g., Center out' per infection control, a physiological must. The text mandates this flow, making the correct, clean intervention.
Question 5 of 5
What are the macrophages found in the epidermis called?
Correct Answer: D
Rationale: Langerhans cells' are epidermal macrophages, per ProProfs. In the spinosum e.g., 2-8% of cells they detect invaders e.g., bacteria triggering immunity e.g., 70% response unlike 'squamous cells' , structural e.g., flat layers. 'Merkel cells' sense touch e.g., fingertips. 'Basal cells' divide e.g., basale, no immunity. An immunologist sees e.g., Skin sentinels' per their antigen role, a physiological must. The quiz names them immune defenders, making the correct, macrophage type.