ATI RN
NCLEX Practice Questions Skin Integrity and Wound Care Questions
Question 1 of 5
The nurse is caring for a patient who is at risk for skin impairment. The patient is able to sit up in a chair. The nurse includes this intervention in the plan of care. How long should the nurse schedule the patient to sit in the chair?
Correct Answer: B
Rationale: Less than 2 hours' is best for chair sitting. Ischial pressure e.g., 60 mmHg exceeds supine e.g., 32 mmHg risking ischemia e.g., 20% after 2 hours unlike '3 hours' , too long e.g., 50% risk. '30 minutes' is short e.g., limits mobility. 'As comfortable' ignores time e.g., unsafe. A nurse schedules e.g., 90 min with cushion' per guidelines, a physiological need. The text caps at 2 hours, making the correct, safe duration.
Question 2 of 5
Protective functions of the skin include all of the following except protection
Correct Answer: A
Rationale: Of the joints' isn't a skin protective function, per ProProfs. Skin guards infections e.g., 98% bacteria block chemicals e.g., pH 5.5 and water loss e.g., 95% retention via epidermis, unlike 'joints' , cartilage/ligament role e.g., not skin's job. A clinician notes e.g., Skin's shield' per barrier focus, a physiological trait. The quiz excludes joints, making the correct, non-protective exception.
Question 3 of 5
What are the two major processes involved in the inflammatory phase of wound healing?
Correct Answer: D
Rationale: Blood clotting is initiated, WBCs move into the wound' are inflammatory phase processes. Clotting e.g., 5 min WBCs e.g., 24 hr clean e.g., 70% debris unlike 'bleeding, epithelial' , later e.g., proliferation. 'Granulation, collagen' is proliferative e.g., day 3. 'Collagen remodeled, scar' is maturation e.g., weeks. A nurse tracks e.g., Clot, fight' per phase 1, a physiological must. The text specifies these, making the correct, early processes.
Question 4 of 5
A nurse is assessing a patient with a stage IV pressure ulcer. What assessment of the ulcer would be expected?
Correct Answer: A
Rationale: Full-thickness skin loss' fits a Stage IV ulcer. Deep e.g., bone visible defines it e.g., 20% cases unlike 'pallor' , Stage I e.g., intact. 'Blisters' are Stage II e.g., partial. 'Eschar' may occur e.g., not required. A nurse expects e.g., Deep hole' per NPUAP, a physiological marker. The text specifies full loss, making the correct, expected finding.
Question 5 of 5
Heat applications are often used to promote tissue healing. What is the rationale for this type of treatment?
Correct Answer: A
Rationale: Physiologic effects of heat accelerate the inflammatory response' is the rationale. Heat e.g., 40°C boosts flow e.g., 2x speeding healing e.g., 30% unlike 'cardiac output' , systemic e.g., not local. 'Reduces flow' reverses e.g., wrong. 'Muscle tension' is secondary e.g., not healing. A nurse explains e.g., Heat speeds' per therapy basis, a physiological truth. The text ties heat to inflammation, making the correct, healing reason.