ATI LPN
Skin Integrity NCLEX Questions Questions
Question 1 of 5
The nurse is caring for a postoperative patient who has had abdominal surgery and whose wound has completely eviscerated when the nurse walks into the room. In addition to notifying the surgeon, what should the nurse do?
Correct Answer: D
Rationale: Moist saline gauze prevents drying and further damage in evisceration until surgical intervention.
Question 2 of 5
The nurse knows what goal to be appropriate for a patient with a stage 3 pressure ulcer with the nursing diagnosis impaired physical mobility?
Correct Answer: C
Rationale: Assisting with position changes addresses impaired mobility directly.
Question 3 of 5
The wound care nurse is monitoring a patient with a Stage III pressure ulcer whose wound presents with healthy tissue. How should the nurse document this ulcer in the patient's medical record?
Correct Answer: C
Rationale: A Stage III ulcer, with full-thickness loss to fat, retains its stage even as it heals. Healing Stage III' , per the flashcards, reflects healthy tissue (e.g., granulation) while preserving original staging for accuracy and care continuity. Stage I is intact skin, not applicable. Healing Stage II underestimates depth. Stage III alone omits healing progress. Proper documentation, per NPUAP guidelines, informs treatment (e.g., moist dressings) and reimbursement, making this the correct choice for nurses.
Question 4 of 5
The nurse caring for a patient in the burn unit should expect what type of wound healing when planning care for this patient?
Correct Answer: B
Rationale: Burns, with tissue loss, heal by secondary intention , per the flashcards, filling with scar tissue over time, raising infection risk. Partial-thickness is for minor wounds. Tertiary intention delays closure. Primary intention is surgical. Nurses manage open burn wounds with dressings and infection control, making this the correct healing type.
Question 5 of 5
Upon entering the room of a patient with a healing Stage III pressure ulcer, the nurse notices an odor and observes a purulent discharge, along with increased redness at the wound site. What action should the nurse give priority to?
Correct Answer: A
Rationale: Signs of infection (odor, pus, redness) require a full assessment , per the flashcards, gathering vitals, labs (e.g., WBC), and treatment data before escalation. Notification follows. Consulting wound care or charge nurse is secondary. Comprehensive data informs care, making this the correct priority.