ATI RN
Skin Integrity and Wound Care NCLEX Questions Questions
Question 1 of 5
The nurse is caring for a patient with a puncture wound. How much time must have passed since the patient's last tetanus toxoid vaccination for the patient to require an additional injection before being discharged from the emergency department?
Correct Answer: D
Rationale: For a dirty puncture wound, '10 years' since last tetanus toxoid triggers a booster, per Potter's *Essentials*. CDC guidelines mandate e.g., after 10 years, immunity wanes (e.g., 50% antibody drop) unlike '1 year' , too soon e.g., still protective. '3 years' and '5 years' apply to cleaner wounds e.g., not this risk. A nurse asks e.g., Last shot 2012?' if over 10 (e.g., 2025 now), injects, reducing tetanus odds (e.g., 1/1000 to near zero). Potter stresses this for dirty trauma, a health promotion must. is the correct, evidence-based cutoff.
Question 2 of 5
The wound care nurse visits a patient in the long-term care unit. The nurse is monitoring a patient with a Stage III pressure ulcer. The wound seems to be healing, and healthy tissue is observed. How should the nurse document this ulcer in the patient's medical record?
Correct Answer: C
Rationale: A healing Stage III ulcer is documented as 'Healing Stage III pressure ulcer'. Stage III e.g., full-thickness, fat visible retains its label e.g., doesn't revert to 'Stage I' , intact redness. 'Healing Stage II' is partial e.g., not this depth. 'Stage III' omits progress e.g., granulation seen. A nurse writes e.g., Healing Stage III, pink tissue' per NPUAP, noting 80% heal thus, a physiological marker. The text mandates healing' addition, making the correct, accurate entry.
Question 3 of 5
The nurse is caring for a patient who has experienced a total abdominal hysterectomy. Which nursing observation of the incision will indicate the patient is experiencing a complication of wound healing?
Correct Answer: D
Rationale: A 'bluish mass' signals a hematoma, a healing complication. Blood under tissue e.g., 50 mL shows swelling e.g., 2 cm unlike 'hurting' , normal e.g., nerve trauma. 'Approximated' is healing e.g., edges shut. 'Itching' is progress e.g., regeneration. A nurse notes e.g., Blue lump' per 10% post-op risk, needing monitoring. The text flags hematoma's vascular threat, making the correct, alarming observation.
Question 4 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 next?
Correct Answer: A
Rationale: A sudden drainage drop prompts 'call the health care provider' . Blockage e.g., clot in tube needs fix e.g., 20% risk unlike 'charting' , passive e.g., delays care. 'Do nothing' risks e.g., compression hides issue. 'Remove drain' is MD's call e.g., not nurse. A nurse acts e.g., No flow, call' per patency rules, a physiological need. The text flags sudden stops, making the correct, proactive step.
Question 5 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.