ATI RN
NCLEX Questions Skin Integrity and Wound Care Questions
Question 1 of 5
The patient has a large left hip decubitus ulcer with tunneling but no involvement of bone, tendon, or muscle. Which pressure injury stage will be recorded in the patient's chart?
Correct Answer: C
Rationale: A hip ulcer with tunneling but no bone is 'Stage 3' , per Potter's *Essentials*. Full-thickness loss e.g., 4 cm deep, fat visible includes tunneling, unlike 'Stage 1' , redness e.g., intact. 'Stage 2' is partial e.g., shallow, no tunnel. 'Stage 4' shows bone e.g., not here. A nurse records e.g., Tunneling 2 cm' Stage 3's 30% rate, per NPUAP, needing packing. Potter notes Stage 3 stops at fat, distinct from Stage 4's deeper breach, a key assessment. is the correct, full-thickness stage.
Question 2 of 5
Which nursing observation will indicate the patient is at risk for pressure ulcer formation?
Correct Answer: A
Rationale: Fecal incontinence' signals pressure ulcer risk. Moisture from stool e.g., 6 hours softens skin, causing maceration e.g., 70% breakdown rate unlike 'two thirds of breakfast' , neutral e.g., not malnutrition. 'Red rash on shin' isn't high-risk e.g., not bony. 'Capillary refill <2 seconds' is normal e.g., no ischemia. A nurse observes e.g., Soiled, wet' needing cleaning, per Braden moisture scale. The text ties moisture to injury over diet or circulation, a physiological integrity clue. is the correct, risk-indicating observation.
Question 3 of 5
A nurse is assessing a patient's wound. Which nursing observation will indicate the wound healed by secondary intention?
Correct Answer: D
Rationale: Scarring that may be severe' indicates secondary intention. Open wounds e.g., ulcers fill with scar e.g., 3 months unlike 'minimal tissue loss' , primary e.g., fast. 'Dark redness' isn't typical e.g., scars lighten. 'Minimal scar tissue' fits primary e.g., surgery. A nurse observes e.g., Thick scar' per 50% of secondary cases, a physiological marker. The text contrasts secondary's heavy scarring with primary's minimal, making the correct, severe sign.
Question 4 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: For a dressing change, 'provide analgesic medications' is first. Pain e.g., 7/10 needs relief e.g., 30 min pre-opioid unlike 'avoid drain removal' , later e.g., during change. 'Don gloves' and 'gather supplies' follow e.g., prep steps. A nurse gives e.g., Morphine 0900' per 80% comfort boost, a basic care priority. The text mandates pain control first, making the correct, initial action.
Question 5 of 5
The nurse collects 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: Ineffective peripheral tissue perfusion' fits a nonblanchable heel. Reduced blood e.g., <15 mmHg causes damage e.g., Stage I unlike 'nutrition' , unlinked e.g., no data. 'Risk for infection' is future e.g., not current. 'Pain' lacks evidence e.g., not noted. A nurse assigns e.g., Poor perfusion' per 60% of early ulcers, a physiological call. The text ties nonblanching to flow, making the correct, perfusion-based diagnosis.