ATI LPN
Skin Integrity and Wound Care NCLEX Questions Questions
Question 1 of 5
The nurse is monitoring a wound in a dark-skinned client for signs of erythema. How would the nurse best determine the presence of erythema?
Correct Answer: D
Rationale: Erythema in dark skin isn't always red. Palpating for increased temperature , per wound assessment texts (e.g., Potter & Perry), detects inflammation reliably, as color changes may appear ashen or purple. Drainage indicates infection, not erythema. Swelling is secondary. Dark skin requires tactile cues over visual, ensuring accurate monitoring for complications like infection, making this the best method.
Question 2 of 5
A nurse is applying a dressing to a wound that has moderate to heavy exudate. Which of the following types of dressing would be most appropriate for this wound?
Correct Answer: D
Rationale: Alginate is the correct answer because it is highly absorbent, capable of managing moderate to heavy exudate by absorbing up to 20 times its weight in fluid, making it ideal for such wounds. It forms a gel when in contact with exudate, maintaining a moist environment that supports healing and autolytic debridement, while preventing maceration of surrounding skin. Transparent film is non-absorbent and suited for dry wounds, offering protection but not fluid management. Hydrogel is minimally absorbent and better for dry or minimally exudative wounds, providing hydration rather than absorption. Foam is moderately absorbent, handling light to moderate exudate, but less effective than alginate for heavy drainage due to its lower capacity (up to four times its weight). The wound's moderate to heavy exudate requires a dressing like alginate to effectively manage fluid and promote optimal healing conditions.
Question 3 of 5
A client is admitted to the hospital with a burn injury covering $30% of the body surface area. The nurse anticipates that the client will require which type of dressing for wound care?
Correct Answer: D
Rationale: Silver dressing is the correct answer because it's ideal for burn injuries covering 30% of the body surface area due to its antimicrobial properties, reducing infection risk a major concern in burns where skin barriers are compromised. Silver ions kill bacteria, manage pain, inflammation, and odor, supporting healing in high-risk wounds. Hydrocolloid dressing is occlusive, suited for minimal-drainage wounds, but can trap bacteria in infected or heavily exudative burns, risking maceration. Hydrogel dressing hydrates dry wounds but lacks sufficient absorption for burn exudate and isn't antimicrobial, making it less suitable. Alginate dressing absorbs heavy exudate but isn't ideal for dry or minimally draining burns and lacks inherent infection control. Given the burn's extent and infection vulnerability, silver dressing offers the best protective and therapeutic benefits.
Question 4 of 5
A nurse is caring for a client who has a pressure ulcer on the sacrum. Which intervention should the nurse perform first?
Correct Answer: D
Rationale: Repositioning the client to relieve pressure on the wound is the correct first intervention. Using the ABCDE framework (Airway, Breathing, Circulation, Disability, Exposure), relieving pressure addresses circulation by preventing further tissue ischemia, the root cause of pressure ulcers. Immediate repositioning halts ongoing damage, enhances blood flow, and sets the stage for subsequent care, making it the priority action. Applying a hydrocolloid dressing promotes healing but doesn't address the immediate threat of pressure, which must stop first. Assessing for infection is crucial but secondary, as it evaluates status rather than intervening to prevent worsening. Cleansing with saline removes debris but doesn't tackle the underlying pressure causing the ulcer. Repositioning is foundational, as unrelieved pressure will negate other interventions' effectiveness, aligning with evidence-based protocols to prioritize tissue perfusion and stop progression in pressure ulcer management.
Question 5 of 5
A nurse is evaluating a client's progress after receiving hyperbaric oxygen therapy (HBOT) for a chronic venous ulcer. Which outcome indicates that HBOT has been effective?
Correct Answer: D
Rationale: Increased granulation tissue in the ulcer is the correct outcome indicating hyperbaric oxygen therapy (HBOT) effectiveness for a chronic venous ulcer. HBOT delivers high-pressure oxygen to enhance tissue oxygenation, stimulating angiogenesis, collagen synthesis, and fibroblast activity, which directly boost granulation tissue formation a hallmark of healing. Reduced pain may occur but isn't specific to HBOT, as analgesics or other factors could contribute, and pain isn't a reliable healing metric. Increased blood oxygen saturation reflects systemic levels, not local tissue oxygenation, which HBOT targets, making it less relevant. Decreased edema could result from compression or elevation, not uniquely HBOT, and isn't a direct healing indicator. Granulation tissue growth ties directly to HBOT's mechanism, providing clear evidence of improved wound bed vitality and progression toward closure.