ATI RN
Skin Integrity and Wound Care NCLEX Questions Quizlet Questions
Question 1 of 5
The nurse is caring for a patient who has perineal skin breakdown after sitting in wet underclothes for many hours. Which term will be used to document the patient's condition in the medical record?
Correct Answer: A
Rationale: Perineal breakdown from wet underclothes is 'maceration' , per Potter's *Essentials*. Prolonged moisture e.g., 6 hours softens skin, causing erosion e.g., red, raw patches unlike 'dehiscence' , surgical separation e.g., above fascia. 'Evisceration' is visceral protrusion e.g., below fascia, not here. 'Debridement' is treatment e.g., removing dead tissue, not condition. A nurse documents e.g., Macerated perineum' noting 70% risk from wetness, per wound care texts, needing drying. Potter defines maceration as moisture-driven, distinct from surgical or intentional terms, a physiological adaptation issue. is the correct, descriptive term.
Question 2 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 3 of 5
A nurse is caring for a postoperative patient. Which finding will alert the nurse to a potential wound dehiscence?
Correct Answer: C
Rationale: A patient's report of 'something has given way' alerts to dehiscence. Skin layers parting e.g., post-cough feels sudden e.g., 5% risk unlike 'organ protrusion' , evisceration e.g., deeper. 'Chronic drainage' hints e.g., not definitive. 'Purulent drainage' is infection e.g., not separation. A nurse assesses e.g., Felt pop' per surgical strain, a physiological red flag. The text ties this sensation to dehiscence, making the correct, early sign.
Question 4 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 5 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.