ATI RN
Fundamentals of Nursing Skin Integrity Questions Questions
Question 1 of 5
The nurse is caring for a patient with a healing Stage III pressure ulcer. Upon entering the room, the nurse notices an odor and observes a purulent discharge, along with increased redness at the wound site. What is the next best step for the nurse?
Correct Answer: A
Rationale: The next best step is 'complete the head-to-toe assessment'. Odor and pus e.g., infection signs need full data e.g., temp 38.5°C, WBC 15,000 unlike 'notify provider' , premature e.g., needs facts. 'Consult wound nurse' and 'check charge nurse' follow e.g., not first. A nurse assesses e.g., Fever, drainage' per 80% infection protocol, a physiological must. The text mandates full assessment first, making the correct, thorough step.
Question 2 of 5
The nurse is performing a moist-to-dry dressing. The nurse has prepared the supplies, solution, and removed the old dressing. In which order will the nurse implement the steps, starting with the first one? 1. Apply sterile gloves. 2. Cover and secure topper dressing. 3. Assess wound and surrounding skin. 4. Moisten gauze with prescribed solution. 5. Gently wring out excess solution and unfold. 6. Loosely pack until all wound surfaces are in contact with gauze.
Correct Answer: B
Rationale: The correct order is '1, 3, 4, 5, 6, 2' . Start with sterile gloves (1) e.g., infection control then assess wound (3) e.g., redness noted moisten gauze (4) e.g., saline wring out (5) e.g., damp, not wet pack wound (6) e.g., 2 cm deep and cover (2) e.g., secure. '4, 3, 1' skips gloves e.g., risky. '4, 1, 3' delays assessment e.g., misses status. '1, 4, 3' misorders e.g., moistens pre-assessment. A nurse follows e.g., Gloves, check, pack' per 100% protocol, a physiological must. The text sequences this, making the correct, systematic order.
Question 3 of 5
The patient has a risk for skin impairment and has a 15 on the Braden Scale upon admission. The nurse has implemented interventions. Upon reassessment, which Braden score will be the best sign that the risk for skin breakdown is removed?
Correct Answer: D
Rationale: A Braden score of '23' best shows risk removed. Perfect score e.g., 6-23 range means no risk e.g., all 4s unlike '12' or '13' , high risk e.g., <16. '20' is safe e.g., >18 but not max. A nurse reassesses e.g., 23, no risk' per 90% intervention success, a physiological goal. The text sets 18 as cutoff, 23 as ideal, making the correct, optimal sign.
Question 4 of 5
What happens when the arrector pili muscles contract?
Correct Answer: A
Rationale: Goose bumps' occur when arrector pili contract, per ProProfs. Tiny muscles e.g., 1 mm raise hairs e.g., cold response unlike 'sweat release' , gland-driven e.g., no link. 'Hair shed' is cycle-based e.g., not instant. 'Skin color change' is vascular e.g., unrelated. A biologist sees e.g., Bumpy chill' per heat/trap instinct, a physiological reaction. The quiz ties this to hair standing, making the correct, bumpy result.
Question 5 of 5
Which of the following best describes an unintentional wound?
Correct Answer: B
Rationale: Jagged wound edges, uncontrolled bleeding' describes an unintentional wound, . Accidents e.g., falls tear e.g., 2 cm, 50 mL unlike 'clean edges' or 'low infection risk' , surgical e.g., planned. 'Surgery, IV' is intentional e.g., not accidental. A nurse sees e.g., Rough, bloody' per trauma type, a physiological distinction. The text contrasts this with intentional, making the correct, unintentional descriptor.