ATI LPN
NCLEX Questions Skin Integrity and Wound Care Questions
Question 1 of 5
The nurse is assessing the perineal wound in a client who has returned from the operating room following an abdominal perineal resection and notes serosanguineous drainage from the wound. Which nursing intervention is most appropriate?
Correct Answer: C
Rationale: Serosanguineous drainage is normal post-op. Changing the dressing as prescribed aligns with wound care standards (e.g., ATI Nursing), managing expected drainage (pink, watery fluid) without escalation. Notifying the surgeon is premature unless excessive. Clamping risks fluid buildup, potentially causing infection. Removing packing disrupts healing unless ordered. Perineal resection wounds typically drain initially; routine dressing changes maintain cleanliness and monitor progress, making this the most appropriate intervention per evidence-based practice.
Question 2 of 5
A client has a wound on the lower leg that is covered with dry, yellow crusts. The nurse recognizes this as an indication of:
Correct Answer: A
Rationale: Slough is the correct answer, as it refers to dead tissue that appears as dry, yellow crusts on a wound's surface, indicating tissue that needs removal to promote healing. Slough can vary in color (white, yellow, green, or brown) and texture (soft, moist, or dry), and its presence suggests the wound is not fully progressing toward recovery without intervention like debridement. Eschar is also dead tissue but is typically black, brown, or tan, with a hard, leathery texture, often serving as a natural barrier in some cases but potentially impeding healing in others. Granulation tissue is healthy, new tissue that appears red or pink, shiny, and moist, signaling active healing, not crusting. Epithelial tissue is the thin, smooth layer forming over granulation tissue in the final healing stages, not matching the dry, yellow description. The dry, yellow crusts clearly point to slough, distinguishing it from the other options based on appearance and role in wound progression.
Question 3 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 4 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 5 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.