ATI LPN
Skin Integrity NCLEX Questions Questions
Question 1 of 9
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 9
Which nursing diagnosis does the nurse add to the care plan for a patient with a Stage IV pressure ulcer?
Correct Answer: C
Rationale: Stage IV ulcers involve severe skin loss, warranting 'Impaired skin integrity' (Choice C), per NANDA-I, reflecting the primary issue. Enhanced nutrition is a goal, not diagnosis. Mobility and pain may coexist but aren't central. This diagnosis drives wound care, making it the correct addition.
Question 3 of 9
You are admitting a patient with an infected abdominal wound with MRSA. Appropriate nursing care includes:
Correct Answer: A
Rationale: MRSA requires infection control. Monitoring temperature and WBC tracks infection, per nursing standards, as fever/leukocytosis signal spread. Intake/output is unrelated. Respiratory precautions fit TB, not MRSA (contact). Hallway ambulation risks transmission. Temp/WBC monitoring guides treatment, an LPN task, making it the correct care.
Question 4 of 9
Which construct do nurses exhibit when they engage in self-reflection about their own cultural beliefs and biases?
Correct Answer: C
Rationale: Self-reflection builds cultural awareness , per Campinha-Bacote's model, recognizing personal biases (e.g., assumptions about pain tolerance) to improve care. Skill is application, desire is motivation, and knowledge is learning. Awareness is foundational, making this the correct construct.
Question 5 of 9
A hospital wishes to implement bar coding in an effort to reduce errors during medication administration. Which of the following would be most helpful during initial design of the new process?
Correct Answer: A
Rationale: Design needs workflow insight. Observing nurses , per the test and Lean principles, reveals real-time barcoding challenges (e.g., scanning barriers), informing process fit. Physician surveys miss administration. Patient focus groups or CNO interviews lack frontline detail. Observation drives usability, making it the correct choice.
Question 6 of 9
Which type of wound healing will the nurse consider when planning care for a patient in the burn unit?
Correct Answer: B
Rationale: Burns, with significant tissue loss, heal by secondary intention (Choice B), per the text, where the wound fills with scar tissue over time, increasing infection risk. Partial-thickness repair is for minor skin loss. Tertiary intention delays closure. Primary intention is for surgical wounds. Secondary intention's prolonged process requires nurses to manage infection and granulation, making this the correct healing type for burn care planning.
Question 7 of 9
Which specialty bed will the nurse use for a patient with a Stage IV pressure ulcer with grafted surgical sites?
Correct Answer: B
Rationale: Air-fluidized beds redistribute pressure via fluid-like immersion, per the text, ideal for Stage IV ulcers with grafts, protecting new tissue. Low-air-loss prevents moisture buildup. Lateral rotation aids pulmonary issues. Standard mattresses lack support. This bed enhances healing, making it the correct choice.
Question 8 of 9
Which action should the nurse perform when teaching a client with LEP and who is from a culture different than their own?
Correct Answer: C
Rationale: LEP and cultural differences need assessment. Performing a health literacy assessment , per nursing practice, gauges understanding (e.g., language, literacy) for tailored teaching. Medical terms confuse. Assuming math skills risks errors. Online research lacks specificity. This ensures effective education, making it the correct action.
Question 9 of 9
The nurse documents the following assessment data: right heel with reddened area that does not blanch. Which nursing diagnosis will the nurse assign to this patient?
Correct Answer: B
Rationale: Nonblanchable redness indicates poor perfusion, fitting Ineffective peripheral tissue perfusion' , per the flashcards. Nutrition , infection , and pain don't match. This targets circulation, making it the correct diagnosis.