ATI LPN
Skin Integrity and Wound Care NCLEX Questions Questions
Question 1 of 5
The nurse is caring for a patient who is experiencing a full-thickness wound repair. Which type of tissue will the nurse expect to observe when the wound is healing?
Correct Answer: C
Rationale: Full-thickness repair produces granulation tissue red, vascular, moist indicating healing progress, per the flashcards. Eschar is necrotic, requiring removal. Slough is dead tissue, impeding repair. Purulent drainage signals infection. Nurses monitor granulation in the proliferative phase, guiding moist dressing use, making this the correct tissue expected.
Question 2 of 5
The nurse is caring for a patient who has a wound drain with a collection device. The nurse notices that the collection device has a sudden decrease in drainage. Which action will the nurse take initially?
Correct Answer: A
Rationale: A sudden drainage drop suggests blockage. Calling the provider (implied Choice A), per nursing practice, is initial to address patency. Options are missing, but charting or ignoring don't fix it. Nurses escalate promptly, making this the correct initial action.
Question 3 of 5
The nurse is caring for a surgical patient. Which intervention is most important for the nurse to complete to decrease the risk of pressure ulcers and encourage the patient's willingness and ability to increase mobility?
Correct Answer: D
Rationale: Pain hinders mobility, increasing ulcer risk. Analgesics , per the flashcards, enhance willingness and ability to move, reducing pressure. Explaining risks educates. Turning every 3 hours is too infrequent. Sitting helps but lacks pain focus. Pain relief is key, making this the correct intervention.
Question 4 of 5
When caring for a group of patients, which task can the nurse delegate to the nursing assistive personnel (AP)?
Correct Answer: B
Rationale: NAPs handle routine tasks. Applying a gauze bandage , per the flashcards, is within their scope, securing dressings safely. Assessing risk , treating ulcers , and negative-pressure therapy require RN judgment. This delegation is appropriate, making it the correct task.
Question 5 of 5
The patient appears anxious as the nurse is preparing to change their wound dressing. Which action should the nurse take?
Correct Answer: B
Rationale: Explaining the procedure , per the flashcards, reduces anxiety by informing and empowering the patient. TV distracts but doesn't address fear. Closing eyes avoids engagement. Waiting for family delays care. This therapeutic approach calms, making it the correct action.