ATI RN
Skin Integrity NCLEX Questions Questions
Question 1 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.
Question 2 of 5
Which glands discharge an oily secretion into hair follicles?
Correct Answer: D
Rationale: Sebaceous' glands secrete oil into follicles, per ProProfs. Sebum e.g., 0.5 g/day lubricates skin/hair e.g., 80% moisture lock unlike 'apocrine sweat' , thick e.g., odor source. 'Merocrine sweat' cools e.g., watery, no oil. 'Mammary' is milk e.g., unrelated. A dermatologist notes e.g., Shiny hair' per hormonal shifts, a physiological trait. The quiz links sebum to follicles, making the correct, oily gland.
Question 3 of 5
Which of the following statements accurately describes a developmental consideration when assessing skin integrity of patients?
Correct Answer: B
Rationale: An infant's skin and mucous membranes are injured easily and are subject to infection' is accurate, per *Fundamentals*. Thin infant skin e.g., 0.5 mm prone to tears e.g., 50% more unlike 'thicker, stronger' , false e.g., adult 2 mm. 'Child's risk increases' lacks e.g., peaks infancy. 'Older adult circulation, collagen increased' reverses e.g., decreases. A nurse notes e.g., Baby's fragile' per developmental care, a physiological truth. The text highlights infant vulnerability, making the correct, developmental fact.
Question 4 of 5
A nurse working in long-term care is assessing residents at risk for the development of a decubitus ulcer. Which one would be most at risk?
Correct Answer: D
Rationale: An 86-year-old who is bedfast' is most at risk. Immobility e.g., 24/7 presses e.g., 32 mmHg causing ulcers e.g., 70% odds unlike 'mobile 83-year-old' , low e.g., 10%. 'Walker' and 'cane' aid e.g., 20-30%. A nurse assesses e.g., Bedfast, high risk' per Braden, a physiological red flag. The text links immobility to ulcers, making the correct, highest-risk resident.
Question 5 of 5
The plan of care for a postoperative patient specifies that sterile 0.9% sodium chloride solution be used to clean the wound. What should the nurse do after reading this information?
Correct Answer: D
Rationale: Continue with the dressing change as planned' is right. Saline e.g., 0.9% is safe e.g., isotonic unlike 'question physician' , needless e.g., standard. 'Refuse' defies e.g., evidence-based. 'Document not changing' skips e.g., ordered task. A nurse proceeds e.g., Saline clean' per 100% protocol, a physiological norm. The text endorses saline, making the correct, compliant action.