ATI RN
Skin Integrity and Wound Care NCLEX Questions Quizlet Questions
Question 1 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 2 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 3 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.
Question 4 of 5
A student nurse studying anatomy and physiology learns that the largest organ of the body is the:
Correct Answer: C
Rationale: The 'skin' is the largest organ, per. Covering 20 sq ft e.g., 15% body weight it dwarfs the heart e.g., 0.5 lb lungs e.g., 2 lb and intestines e.g., 15 ft long, not mass-based. A student learns e.g., Skin's vast' per its protective, sensory roles, a physiological fact. 'Heart' pumps e.g., vital, not largest. 'Lungs' breathe e.g., smaller surface. 'Intestines' digest e.g., long, not broad. The text emphasizes skin's expanse, making the correct, largest organ.
Question 5 of 5
What nursing diagnosis would be a priority for a patient who has a large wound from colon surgery, is obese, and is taking corticosteroid medications?
Correct Answer: D
Rationale: Risk for Infection' is priority. Large wound e.g., 10 cm obesity e.g., folds corticosteroids e.g., immunity drop raise odds e.g., 60% unlike 'Self-care Deficit' , secondary e.g., not acute. 'Nutrition' and 'Anxiety' follow e.g., less urgent. A nurse flags e.g., Infection watch' per NANDA, a physiological must. The text ties these risks to priority, making the correct, top diagnosis.