ATI LPN
Skin Integrity NCLEX Questions Questions
Question 1 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 2 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 3 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.
Question 4 of 5
The nurse caring for a patient with a pressure ulcer on the left hip that is black. Which next step will the nurse anticipate?
Correct Answer: C
Rationale: Black tissue is necrotic, requiring debridement (implied Choice C), per nursing standards, to remove infection and aid healing. Options are missing, but monitoring or drainage aren't next. Nurses anticipate this, making it the correct step.
Question 5 of 5
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.