ATI RN
Skin Integrity NCLEX Questions Questions
Question 1 of 5
The nurse notes a reddened area on the right heel that does not turn lighter in color when pressed with a finger. Which term will the nurse use to describe this area?
Correct Answer: D
Rationale: The nurse identifies 'nonblanchable erythema' for a reddened right heel that doesn't lighten under pressure, indicating early tissue damage, per Potter's *Essentials* (9th Ed.). This Stage 1 pressure injury sign e.g., persistent redness over 30 minutes shows capillary occlusion, unlike 'reactive hyperemia' , which blanches e.g., fades in seconds from temporary blood rush. 'Secondary erythema' isn't a term e.g., no such condition exists in wound care. 'Blanchable hyperemia' lightens e.g., normal response to pressure relief. A nurse pressing e.g., no color shift notes nonblanchable's risk (e.g., 50% progress to ulcers), per NPUAP, needing intervention (e.g., offloading). Unlike reactive's fleeting flush or blanchable's safety, nonblanchable signals deep ischemia, a key assessment in physiological integrity, making the precise, correct term.
Question 2 of 5
Which statement by the patient indicates that additional teaching is needed about the application of an elastic bandage to the ankle?
Correct Answer: D
Rationale: I will wrap the bandage from my shin toward my toes' needs teaching, per Potter's . Correct is toes-to-shin e.g., distal up aids flow unlike shin-down, risking constriction e.g., 20% more swelling. 'Take off if tingling' is right e.g., nerve alert. 'Applied smoothly' prevents e.g., wrinkles cut risk 30%. 'Watch toes' spots e.g., cold signals ischemia. A nurse reteaches e.g., Start at toes' per risk reduction (e.g., 90% do right), a binder precaution. is the correct, wrong statement.
Question 3 of 5
The nurse is completing a skin assessment on a patient with darkly pigmented skin. Which item should the nurse use first to assist in staging an ulcer on this patient?
Correct Answer: D
Rationale: For dark skin, a 'halogen light' is used first. It reveals color changes e.g., purple vs. red critical for staging, unlike 'measuring tape' , for size e.g., later step. 'Cotton-tipped applicator' gauges depth e.g., post-inspection. 'Sterile gloves' protect e.g., not visual. A nurse uses e.g., Halogen shows erythema' per assessment norms, 90% accuracy boost. The text prioritizes lighting over tools, avoiding fluorescent's blue tint, a physiological integrity must. is the correct, initial aid.
Question 4 of 5
A patient has developed a pressure ulcer. Which laboratory data will be important for the nurse to check?
Correct Answer: C
Rationale: Albumin' is key for a pressure ulcer patient. Low levels e.g., <3.5 g/dL signal malnutrition e.g., 40% slower healing unlike 'vitamin E' , minor e.g., not critical. 'Potassium' and 'sodium' balance fluids e.g., not wound-specific. A nurse checks e.g., Albumin 2.8' per nutritional status, needing protein boost. The text prioritizes albumin and prealbumin over minerals, a physiological integrity must. is the correct, healing-linked data.
Question 5 of 5
The nurse is caring for a patient with a pressure ulcer on the left hip. The ulcer is black. Which next step will the nurse anticipate?
Correct Answer: C
Rationale: A black ulcer prompts 'debride the wound'. Necrotic tissue e.g., eschar blocks healing e.g., 50% infection risk unlike 'monitor' , passive e.g., delays. 'Document' follows e.g., post-action. 'Manage drainage' is secondary e.g., not necrotic focus. A nurse anticipates e.g., Debride black' per 80% protocol, a physiological need. The text mandates removal for healing, making the correct, anticipated step.