ATI LPN
Skin Integrity and Wound Care NCLEX Questions Quizlet Questions
Question 1 of 5
The nurse is caring for a client with a Penrose drain from an abdominal incision. Which is an appropriate nursing intervention for this client?
Correct Answer: B
Rationale: Penrose drains are passive. Measuring drainage , per nursing protocols, tracks output accurately, aiding fluid balance assessment. Safety pins secure but aren't sterile post-insertion. Suction or squeezing applies to active drains (e.g., Jackson-Pratt), not Penrose. Quantifying drainage informs care (e.g., infection risk), making this appropriate for this drain type.
Question 2 of 5
A nurse is evaluating the effectiveness of negative pressure wound therapy (NPWT) on a client with a chronic wound. Which of the following outcomes would indicate that the therapy is successful?
Correct Answer: B
Rationale: as decreased drainage indicates successful negative pressure wound therapy (NPWT). NPWT uses a vacuum to remove excess fluid, debris, and infectious material from the wound, reducing drainage, edema, and bacterial load while promoting blood flow and granulation tissue formation key signs of healing. An increase in wound size suggests worsening or tissue damage, countering NPWT's goal of wound closure. Increased pain could indicate complications like infection or improper application, not success, as NPWT should enhance comfort by reducing inflammation. Decreased granulation tissue would signal poor healing, as NPWT aims to stimulate this tissue's growth, not diminish it. Decreased drainage aligns with NPWT's mechanism of action, reflecting effective fluid management and progression toward wound recovery.
Question 3 of 5
A nurse is evaluating a client's response to negative pressure wound therapy (NPWT). Which outcome indicates that the therapy is effective?
Correct Answer: A
Rationale: Decreased edema in the wound area is the correct answer, as it shows negative pressure wound therapy (NPWT) is working effectively. NPWT applies suction to remove excess fluid, reducing swelling, improving circulation, and fostering a healing environment by decreasing edema. Increased drainage would suggest NPWT isn't managing fluid properly, as it should reduce, not increase, exudate. Decreased granulation tissue indicates poor healing, as NPWT aims to boost this tissue's growth, not diminish it. Increased eschar reflects failure, as NPWT should aid debridement, not promote necrotic tissue buildup. Reduced edema aligns with NPWT's mechanism enhancing blood flow and fluid removal making it a clear indicator of success in supporting wound recovery.
Question 4 of 5
A client is admitted to the hospital with a diabetic foot ulcer. The nurse notes that the wound has a black, dry, and hard eschar covering most of its surface. Which action should the nurse take?
Correct Answer: D
Rationale: Consulting with the provider about surgical debridement is the correct action for a diabetic foot ulcer with black, dry, hard eschar. Eschar indicates significant necrotic tissue, which delays healing and heightens infection risk in diabetic patients, who are prone to complications due to poor vascularity and immune response. Surgical debridement swiftly removes this barrier, exposing viable tissue for healing, and is the most efficient method for extensive necrosis. Wet-to-dry dressings are outdated and inappropriate for dry eschar, as they're better for moist slough and can harm healthy tissue. Transparent film traps moisture but doesn't address necrosis, risking infection beneath the eschar. Leaving it open to air invites contamination and drying, slowing recovery. Given the wound's severity and diabetes context, consulting for surgical intervention ensures timely, effective management, reducing risks like osteomyelitis or amputation.
Question 5 of 5
A nurse is assessing a client with a pressure ulcer on the sacrum. Which finding should the nurse report to the provider immediately?
Correct Answer: A
Rationale: Foul odor and purulent drainage is the correct finding to report immediately, as it signals an acute infection in the pressure ulcer. This combination suggests bacterial proliferation, potentially leading to sepsis or deeper tissue damage, requiring urgent provider intervention, wound culture, and possibly antibiotics. Black, necrotic tissue indicates eschar, which needs debridement but isn't immediately life-threatening unless unstable or infected, manageable by the wound team. Red, granulating tissue is a healthy sign of healing, not a concern. Yellow, sloughing tissue represents slough, which delays healing but isn't an emergency unless paired with infection signs. The foul odor and purulent drainage escalate the situation to critical, demanding prompt reporting to prevent systemic complications, distinguishing it as the priority among these findings.