ATI LPN
NCLEX Questions Skin Integrity and Wound Care Questions
Question 1 of 5
The nurse is completing a skin risk assessment using the Braden Scale. The patient has slight sensory impairment, has skin that is rarely moist, walks occasionally, and has slightly limited mobility, along with excellent intake of meals and no apparent problem with friction and shear. Which score will the nurse document for this patient?
Correct Answer: C
Rationale: Braden scores (6-23) assess risk; higher is better. Per the flashcards: slight sensory (3), rarely moist (4), walks occasionally (3), slight mobility (3), excellent intake (4), no friction/shear (4) = 20 . This is moderate risk, making it the correct score.
Question 2 of 5
The nurse leaves a pressure ulcer open to air and does not apply a dressing. Which stage pressure ulcer does this patient have?
Correct Answer: A
Rationale: Stage I ulcers intact, red heal without dressings , per the flashcards, resolving in 7-14 days with relief. Stage II , III , and IV need dressings for deeper damage. Open-to-air suits Stage I, making this the correct stage.
Question 3 of 5
Which action should the nurse take to meet the nutritional needs of a Jewish client?
Correct Answer: B
Rationale: Culturally sensitive care respects individual beliefs. Asking the client about dietary preferences ensures the nurse addresses specific Jewish dietary laws (e.g., kosher), which vary (e.g., avoiding pork or mixing dairy and meat). Ordering a kosher meal assumes uniformity, risking oversight of personal variations. Paper plates are irrelevant to nutrition. Consulting a dietitian is secondary without client input. Per nursing principles, understanding the client's needs first fosters trust and tailors care, aligning with transcultural models like Leininger's, making this the correct action.
Question 4 of 5
The nurse is caring for a client who is reluctant to take pain medication, fearing that if they do so others will see them as weak. Which of the following statements best describes how the nurse should initially respond?
Correct Answer: A
Rationale: Cultural humility starts with understanding. Acknowledging cultural influences and listening , per nursing standards, respects the client's fear of weakness (e.g., stoicism in some cultures) and builds trust. Education or encouragement (Choices C, D) without context may dismiss beliefs, risking resistance. Initial listening informs tailored care, making this the correct response.
Question 5 of 5
A nurse is providing care to an older adult client who follows a traditional cultural practice of using herbal remedies alongside prescribed medications. How can the nurse incorporate the client's cultural practice of using herbal remedies into the plan of care while ensuring the client's safety and well-being?
Correct Answer: C
Rationale: Safety and culture balance via collaboration. Assessing safety and interactions , per nursing standards, integrates herbal use (e.g., checking for drug-herb conflicts like St. John's Wort) with medical care. Education to stop dismisses beliefs. Herbalist referral shifts responsibility. Disregarding lacks respect. This ensures holistic care, making it the correct action.