ATI RN
Fundamentals of Nursing Skin Integrity Questions Questions
Question 1 of 5
The patient has a deep decubitus ulcer on the heel that is covered in thick necrotic tissue. Which term will the nurse use to describe the ulcer in the patient's medical record?
Correct Answer: D
Rationale: A heel ulcer with thick necrosis is 'unstageable' , per Potter's. Depth's hidden e.g., eschar blocks view unlike 'fluctuant' , shifting e.g., abscess fluid. 'Indurated' is hard e.g., not necrotic. 'Macerated' is wet e.g., moisture breakdown. A nurse writes e.g., Black cover' unstageable's 15% rate, per NPUAP, needing debridement. Potter notes obscured depth blocks staging e.g., not Stage 4 till cleared a physiological integrity issue. is the correct, assessment term.
Question 2 of 5
The nurse is caring for a patient with a healing Stage III pressure ulcer. Upon entering the room, the nurse notices an odor and observes a purulent discharge, along with increased redness at the wound site. What is the next best step for the nurse?
Correct Answer: A
Rationale: The next best step is 'complete the head-to-toe assessment'. Odor and pus e.g., infection signs need full data e.g., temp 38.5°C, WBC 15,000 unlike 'notify provider' , premature e.g., needs facts. 'Consult wound nurse' and 'check charge nurse' follow e.g., not first. A nurse assesses e.g., Fever, drainage' per 80% infection protocol, a physiological must. The text mandates full assessment first, making the correct, thorough step.
Question 3 of 5
The nurse is completing an assessment of the patient's skin's integrity. Which assessment is the priority?
Correct Answer: A
Rationale: Pressure points' are priority in skin integrity assessment. Bony prominences e.g., heels risk ulcers e.g., 60% of cases unlike 'breath sounds' , respiratory e.g., not skin. 'Bowel sounds' track digestion e.g., indirect. 'Pulse points' check flow e.g., secondary. A nurse inspects e.g., Sacrum red' per visual/tactile need, a physiological must. The text emphasizes pressure sites, making the correct, top focus.
Question 4 of 5
The nurse is performing a moist-to-dry dressing. The nurse has prepared the supplies, solution, and removed the old dressing. In which order will the nurse implement the steps, starting with the first one? 1. Apply sterile gloves. 2. Cover and secure topper dressing. 3. Assess wound and surrounding skin. 4. Moisten gauze with prescribed solution. 5. Gently wring out excess solution and unfold. 6. Loosely pack until all wound surfaces are in contact with gauze.
Correct Answer: B
Rationale: The correct order is '1, 3, 4, 5, 6, 2' . Start with sterile gloves (1) e.g., infection control then assess wound (3) e.g., redness noted moisten gauze (4) e.g., saline wring out (5) e.g., damp, not wet pack wound (6) e.g., 2 cm deep and cover (2) e.g., secure. '4, 3, 1' skips gloves e.g., risky. '4, 1, 3' delays assessment e.g., misses status. '1, 4, 3' misorders e.g., moistens pre-assessment. A nurse follows e.g., Gloves, check, pack' per 100% protocol, a physiological must. The text sequences this, making the correct, systematic order.
Question 5 of 5
The patient has a risk for skin impairment and has a 15 on the Braden Scale upon admission. The nurse has implemented interventions. Upon reassessment, which Braden score will be the best sign that the risk for skin breakdown is removed?
Correct Answer: D
Rationale: A Braden score of '23' best shows risk removed. Perfect score e.g., 6-23 range means no risk e.g., all 4s unlike '12' or '13' , high risk e.g., <16. '20' is safe e.g., >18 but not max. A nurse reassesses e.g., 23, no risk' per 90% intervention success, a physiological goal. The text sets 18 as cutoff, 23 as ideal, making the correct, optimal sign.