ATI LPN
NCLEX Questions Skin Integrity and Wound Care Questions
Question 1 of 5
The nurse is caring for a patient on the medical-surgical unit with a wound that has a drain and a dressing that needs changing. Which action should the nurse take first?
Correct Answer: A
Rationale: Dressing changes hurt. Providing analgesics first , per the flashcards, eases pain 30 minutes prior, aiding cooperation. Avoiding drain removal , gloves , and supplies follow. Pain management sets the stage, making this the correct first action.
Question 2 of 5
The nurse is caring for a patient with a Stage II pressure ulcer and has assigned a nursing diagnosis of Risk for infection. The patient is unconscious and bedridden. Which is the best goal for this patient?
Correct Answer: D
Rationale: Measurable goals suit unconscious patients. Remain free of odorous or purulent drainage' , per the flashcards, indicates no infection. Stating signs isn't possible. Family actions (Choices B, C) are interventions. This reflects prevention, making it the correct goal.
Question 3 of 5
The nurse leaves a pressure ulcer open to air and does not apply a dressing. Which stage pressure ulcer does this patient have?
Correct Answer: A
Rationale: Stage I ulcers intact, red heal without dressings , per the flashcards, resolving in 7-14 days with relief. Stage II , III , and IV need dressings for deeper damage. Open-to-air suits Stage I, making this the correct stage.
Question 4 of 5
Which action should the nurse take to meet the nutritional needs of a Jewish client?
Correct Answer: B
Rationale: Culturally sensitive care respects individual beliefs. Asking the client about dietary preferences ensures the nurse addresses specific Jewish dietary laws (e.g., kosher), which vary (e.g., avoiding pork or mixing dairy and meat). Ordering a kosher meal assumes uniformity, risking oversight of personal variations. Paper plates are irrelevant to nutrition. Consulting a dietitian is secondary without client input. Per nursing principles, understanding the client's needs first fosters trust and tailors care, aligning with transcultural models like Leininger's, making this the correct action.
Question 5 of 5
The nurse is caring for a client who is reluctant to take pain medication, fearing that if they do so others will see them as weak. Which of the following statements best describes how the nurse should initially respond?
Correct Answer: A
Rationale: Cultural humility starts with understanding. Acknowledging cultural influences and listening , per nursing standards, respects the client's fear of weakness (e.g., stoicism in some cultures) and builds trust. Education or encouragement (Choices C, D) without context may dismiss beliefs, risking resistance. Initial listening informs tailored care, making this the correct response.