ATI LPN
Skin Integrity and Wound Care NCLEX Questions Questions
Question 1 of 5
The nurse understands which rationale to be appropriate for drying a wound after irrigation?
Correct Answer: C
Rationale: Drying prevents moisture-related skin breakdown, not infection or dressing adhesion.
Question 2 of 5
The nurse is caring for a patient who is experiencing a full-thickness wound repair. Which type of tissue will the nurse expect to observe when the wound is healing?
Correct Answer: C
Rationale: Full-thickness repair produces granulation tissue red, vascular, moist indicating healing progress, per the flashcards. Eschar is necrotic, requiring removal. Slough is dead tissue, impeding repair. Purulent drainage signals infection. Nurses monitor granulation in the proliferative phase, guiding moist dressing use, making this the correct tissue expected.
Question 3 of 5
Which laboratory data will be important for the nurse to monitor when a patient develops a pressure ulcer?
Correct Answer: C
Rationale: Prealbumin , per the flashcards, reflects nutritional status for healing, dropping (<20 mg/dL) in malnutrition a pressure ulcer risk. Vitamin E isn't key. Potassium and sodium are electrolytes, not healing-specific. Nurses track prealbumin over albumin for recent intake, making this the correct data.
Question 4 of 5
The nurse is caring for a patient who has a wound drain with a collection device. The nurse notices that the collection device has a sudden decrease in drainage. Which action will the nurse take initially?
Correct Answer: A
Rationale: A sudden drainage drop suggests blockage. Calling the provider (implied Choice A), per nursing practice, is initial to address patency. Options are missing, but charting or ignoring don't fix it. Nurses escalate promptly, making this the correct initial action.
Question 5 of 5
The nurse is caring for a surgical patient. Which intervention is most important for the nurse to complete to decrease the risk of pressure ulcers and encourage the patient's willingness and ability to increase mobility?
Correct Answer: D
Rationale: Pain hinders mobility, increasing ulcer risk. Analgesics , per the flashcards, enhance willingness and ability to move, reducing pressure. Explaining risks educates. Turning every 3 hours is too infrequent. Sitting helps but lacks pain focus. Pain relief is key, making this the correct intervention.