ATI RN
NCLEX Questions on Skin Integrity and Wound Care Questions
Question 1 of 5
The nurse is caring for a patient with a Stage IV pressure ulcer. Which nursing diagnosis does the nurse add to the care plan?
Correct Answer: C
Rationale: Impaired skin integrity' fits a Stage IV ulcer. Deep damage e.g., bone exposed defines this e.g., 20% incidence unlike 'enhanced nutrition' , positive e.g., not current. 'Mobility' is risk e.g., not diagnosis. 'Chronic pain' may coexist e.g., not primary. A nurse adds e.g., Impaired integrity' per NANDA, a physiological focus. The text links Stage IV to skin loss, making the correct, specific diagnosis.
Question 2 of 5
Which fibrous protein is responsible for the strength and water resistance of the skin surface?
Correct Answer: D
Rationale: Keratin' ensures skin strength and water resistance, per ProProfs. In the epidermis e.g., stratum corneum it hardens via keratinization e.g., 15-day cycle forming a barrier e.g., 95% waterproof unlike 'keratohyalin' , a precursor e.g., granulosum role. 'Eleidin' is intermediate e.g., lucidum, not key. 'Collagen' supports dermis e.g., deeper, not surface. A histologist sees e.g., Tough outer shell' per its protective role, a physiological must. The quiz highlights keratin's surface dominance, making the correct, fibrous protein.
Question 3 of 5
Hair follicles and fingernails originate in the but are actually derived from tissue.
Correct Answer: C
Rationale: Dermis; epidermal' fits hair and nails, per ProProfs. Follicles root in dermis e.g., 2 mm deep but grow from epidermal cells e.g., keratin unlike 'subcutaneous; connective' , fat e.g., no origin. 'Dermis; subcutaneous' reverses e.g., wrong source. 'Epidermis; dermal' flips e.g., incorrect. A histologist sees e.g., Dermis base, epidermis build' per layered roles, a physiological must. The quiz specifies this origin, making the correct, dual-tissue answer.
Question 4 of 5
A nurse is caring for a patient who is 2 days postoperative after abdominal surgery. What nursing intervention would be important to promote wound healing at this time?
Correct Answer: B
Rationale: Assist in moving to prevent strain on the suture line' promotes healing. Day 2 e.g., inflammation needs support e.g., 50% less tension unlike 'pain meds' , comfort e.g., not direct healing. 'Mild fever normal' informs e.g., not action. 'Scar limits movement' is late e.g., irrelevant now. A nurse aids e.g., Lift, don't pull' per suture care, a physiological need. The text prioritizes strain relief, making the correct, healing intervention.
Question 5 of 5
During a dressing change, the nurse assesses protrusion of intestines through an opened wound. What would the nurse do after covering the wound with towels moistened with sterile 0.9% sodium chloride solution?
Correct Answer: D
Rationale: Notify the physician and prepare for surgery' follows evisceration. Intestines out e.g., 5 cm needs OR e.g., 100% urgent unlike 'document' , later e.g., post-action. 'Reinforce' delays e.g., not enough. 'Pain meds' secondary e.g., not fix. A nurse acts e.g., Call MD, prep' per protocol, a physiological emergency. The text mandates this, making the correct, next step.