ATI LPN
NCLEX Questions Skin Integrity and Wound Care Questions
Question 1 of 5
The nurse is repositioning the patient in the side-lying position. To avoid putting the patient at risk for pressure ulcers, the nurse should place the head of the bed in which position?
Correct Answer: C
Rationale: A 30-degree angle avoids direct pressure on bony prominences like the trochanter.
Question 2 of 5
A nurse participating in a research project associated with pressure ulcers will assess for what predisposing factor that tends to increase the risk for pressure ulcer development?
Correct Answer: A
Rationale: Pressure ulcers arise from unrelieved pressure impairing tissue perfusion. Decreased level of consciousness heightens risk, per nursing principles, as patients can't sense or relieve pressure, aligning with Braden Scale's sensory perception category. These patients, often bedridden or confused, miss cues to shift positions, increasing ischemic damage over bony prominences like the sacrum. Adequate dietary intake supports healing, not risk. Shortness of breath impacts oxygenation but isn't a direct factor. Muscular pain may reduce mobility but isn't primary. Research prioritizes consciousness as a measurable, prevalent risk factor nurses assess, making this the correct choice.
Question 3 of 5
Which patient will the nurse see first?
Correct Answer: C
Rationale: Priority follows acuity. Appendicitis with a heating pad , per the flashcards, risks rupture an emergency outweighing a chronic Stage IV ulcer . A Braden score of 18 is low risk. An approximated incision is normal. Heat exacerbates inflammation, per nursing principles, demanding immediate nurse action to prevent peritonitis, making this the correct first patient.
Question 4 of 5
Which finding will alert the nurse to a potential wound dehiscence in a postoperative patient?
Correct Answer: C
Rationale: Dehiscence wound layer separation often presents with a patient feeling something has given way' , per the flashcards, especially post-strain (e.g., coughing). Options A, B, and D are incomplete, but organ protrusion (evisceration) or drainage differ. This report triggers urgent nurse assessment, making it the correct alert.
Question 5 of 5
The nurse is caring for a patient on the medical-surgical unit with a wound that has a drain and a dressing that needs changing. Which action should the nurse take first?
Correct Answer: A
Rationale: Dressing changes hurt. Providing analgesics first , per the flashcards, eases pain 30 minutes prior, aiding cooperation. Avoiding drain removal , gloves , and supplies follow. Pain management sets the stage, making this the correct first action.