The nurse is caring for a patient who is immobile. The nurse wants to decrease the formation of pressure ulcers. Which action will the nurse take first?

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Skin Integrity and Wound Care NCLEX Questions Questions

Question 1 of 5

The nurse is caring for a patient who is immobile. The nurse wants to decrease the formation of pressure ulcers. Which action will the nurse take first?

Correct Answer: C

Rationale: Determine the patient's risk factors' is first. Assessing e.g., Braden score guides prevention e.g., 16 flags 50% risk unlike 'fluids' , secondary e.g., hydration. 'Turn q2h' follows e.g., intervention. 'Carbs/fats' is vague e.g., not priority. A nurse starts e.g., Check mobility' per protocol, a physiological must. The text mandates risk first, making the correct, initial action.

Question 2 of 5

What happens when the body temperature rises above normal?

Correct Answer: D

Rationale: Blood flow to the skin increases' when temperature rises, per ProProfs. Vasodilation e.g., 2x flow cools via heat loss e.g., 37.5°C to 36°C unlike 'decreases' , for cold e.g., conserve heat. 'Melanocyte activity' isn't thermal e.g., UV-driven. 'Vasoconstriction' retains heat e.g., opposite. A clinician notes e.g., Flushed face' per thermoregulation, a physiological response. The quiz ties this to cooling, making the correct, heat-dissipating action.

Question 3 of 5

What usually happens to the skin when there is a decrease in the amount of oxygen in the blood?

Correct Answer: A

Rationale: Cyanosis' occurs with low blood oxygen, per ProProfs. Blue tint e.g., lips, 90% SpOâ‚‚ reflects deoxygenated blood e.g., 20% darker unlike 'jaundice' , yellow e.g., liver issue. 'Paleness' is blood loss e.g., not oxygen. 'Flushing' is heat e.g., opposite. A nurse spots e.g., Blue fingertips' per respiratory link, a physiological sign. The quiz names cyanosis, making the correct, hypoxic response.

Question 4 of 5

A nurse is teaching a postoperative patient about essential nutrition for healing. What statement by the patient would indicate a need for more information?

Correct Answer: C

Rationale: I will restrict my diet to fats and carbohydrates' needs more teaching. Healing requires protein e.g., 1.5 g/kg not just fats/carbs e.g., energy, 40% deficit unlike 'orange juice, milk' , vitamin C e.g., collagen. 'Zinc' aids e.g., 15 mg/day. 'Water' hydrates e.g., 2 L. A nurse corrects e.g., Add protein' per nutritional needs, a physiological gap. The text stresses balanced intake, making the correct, misinformation signal.

Question 5 of 5

A nurse assessing a patient's wound documents the finding of purulent drainage. What is the composition of this type of drainage?

Correct Answer: D

Rationale: White blood cells, debris, bacteria' compose purulent drainage. Thick, yellow e.g., infection shows WBCs e.g., 10mL unlike 'clear blood' , serous e.g., thin. 'RBCs' is sanguineous e.g., red. 'Serum, RBCs' is serosanguineous e.g., pink. A nurse notes e.g., Pus, thick' per 90% infection sign, a physiological marker. The text defines this, making the correct, purulent mix.

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