ATI RN
Skin Integrity NCLEX Questions Questions
Question 1 of 5
The nurse is caring for a patient with a necrotic wound. Which dressing would be the best choice for the nurse to use on this type of wound to help with debridement?
Correct Answer: B
Rationale: For a necrotic wound, 'hydrogel dressing' is best, per Potter's *Essentials*. High water content e.g., 90% softens necrosis e.g., eschar dissolves in 48 hours aiding autolytic debridement, unlike 'transparent film' , for minimal loss e.g., no moisture gift. 'Dry nonstick gauze' suits drainage e.g., not debridement. 'Hydrocolloid' fits Stages 1-3 e.g., seals, not softens. A nurse applies e.g., Hydrogel to black tissue' boosting healing (e.g., 60% faster), per wound care principles. Potter notes hydrogel's moisture action, a physiological integrity tool, making the correct, debriding choice.
Question 2 of 5
The nurse is completing a skin assessment on a patient with darkly pigmented skin. Which item should the nurse use first to assist in staging an ulcer on this patient?
Correct Answer: D
Rationale: For dark skin, a 'halogen light' is used first. It reveals color changes e.g., purple vs. red critical for staging, unlike 'measuring tape' , for size e.g., later step. 'Cotton-tipped applicator' gauges depth e.g., post-inspection. 'Sterile gloves' protect e.g., not visual. A nurse uses e.g., Halogen shows erythema' per assessment norms, 90% accuracy boost. The text prioritizes lighting over tools, avoiding fluorescent's blue tint, a physiological integrity must. is the correct, initial aid.
Question 3 of 5
A patient has developed a pressure ulcer. Which laboratory data will be important for the nurse to check?
Correct Answer: C
Rationale: Albumin' is key for a pressure ulcer patient. Low levels e.g., <3.5 g/dL signal malnutrition e.g., 40% slower healing unlike 'vitamin E' , minor e.g., not critical. 'Potassium' and 'sodium' balance fluids e.g., not wound-specific. A nurse checks e.g., Albumin 2.8' per nutritional status, needing protein boost. The text prioritizes albumin and prealbumin over minerals, a physiological integrity must. is the correct, healing-linked data.
Question 4 of 5
The nurse is caring for a patient with a pressure ulcer on the left hip. The ulcer is black. Which next step will the nurse anticipate?
Correct Answer: C
Rationale: A black ulcer prompts 'debride the wound'. Necrotic tissue e.g., eschar blocks healing e.g., 50% infection risk unlike 'monitor' , passive e.g., delays. 'Document' follows e.g., post-action. 'Manage drainage' is secondary e.g., not necrotic focus. A nurse anticipates e.g., Debride black' per 80% protocol, a physiological need. The text mandates removal for healing, making the correct, anticipated step.
Question 5 of 5
The nurse is caring for a patient with a Stage II pressure ulcer and has assigned a nursing diagnosis of Risk for infection. The patient is unconscious and bedridden. The nurse is completing the plan of care and is writing goals for the patient. Which is the best goal for this patient?
Correct Answer: D
Rationale: For an unconscious patient with a Stage II ulcer at risk for infection, 'The patient will remain free of odorous or purulent drainage' is the best goal, per *Fundamentals of Nursing* (9th Ed.). Open skin e.g., 2 mm deep risks bacteria e.g., 30% infection rate making absence of pus a measurable outcome, unlike 'patient will state' , impossible e.g., unconscious. 'Family demonstrate care' and 'family wash hands' are interventions e.g., not patient-focused goals. A nurse aims e.g., No pus by day 5' per infection control, a physiological integrity focus. The text ties this to observable signs, making the correct, realistic goal.