ATI RN
NCLEX Questions on Skin Integrity and Wound Care Questions
Question 1 of 5
The patient has a large red, blistered area on the left hip. Which pressure injury stage will be recorded in the patient's chart?
Correct Answer: B
Rationale: A red, blistered hip area is 'Stage 2' , per Potter's *Essentials*. Partial-thickness loss e.g., ruptured blister 3 cm wide shows dermis, unlike 'Stage 1' , intact redness e.g., no break. 'Stage 3' is full-thickness e.g., fat, not blister. 'Stage 4' exposes bone e.g., deeper than skin. A nurse charts e.g., Blister open, pink' Stage 2's 40% incidence, per NPUAP, needing nonadherent dressing. Potter defines Stage 2 as shallow with no slough, distinct from Stage 3's depth, a physiological integrity marker. is the correct, dermal stage.
Question 2 of 5
Which priority element will the nurse consider when planning care to decrease the development of a decubitus ulcer for a patient who sustained a head injury and is unconscious?
Correct Answer: B
Rationale: Pressure' is the priority to reduce decubitus ulcers in an unconscious patient. Pressure intensity e.g., >32 mmHg duration e.g., 2 hours and tissue tolerance cause ischemia e.g., sacral redness unlike 'resistance' , vague e.g., not a factor. 'Weight' contributes e.g., bony pressure but isn't primary. 'Stress' is emotional e.g., not mechanical. A nurse plans e.g., Turn q2h' cutting 60% of risk, per studies, a physiological focus. The text emphasizes pressure's role over secondary elements, making the correct, critical element.
Question 3 of 5
The nurse is caring for a patient in the burn unit. Which type of wound healing will the nurse consider when planning care for this patient?
Correct Answer: B
Rationale: Burns heal by 'secondary intention'. Tissue loss e.g., 3rd-degree fills with scar e.g., weeks unlike 'partial-thickness' , epidermal e.g., minor burns. 'Tertiary intention' delays e.g., not typical. 'Primary intention' is closed e.g., surgery. A nurse plans e.g., Moist dressings' per 60% burn cases, a physiological need. The text notes secondary's slow, infection-prone path, making the correct, open healing type.
Question 4 of 5
A patient presents to the emergency department with a laceration of the right forearm caused by a fall. After determining that the patient is stable, what is the next best step for the nurse to take?
Correct Answer: B
Rationale: After stability, 'inspect the wound for bleeding' is next. Lacerations bleed e.g., 50 mL needing control e.g., pressure unlike 'foreign bodies' , later e.g., post-hemostasis. 'Size' follows e.g., for sutures. 'Tetanus' is last e.g., history-based. A nurse checks e.g., Active bleed' per 90% of trauma protocol, a physiological must. The text prioritizes bleeding, making the correct, urgent step.
Question 5 of 5
The nurse is caring for a patient with a Stage IV pressure ulcer. Which nursing diagnosis does the nurse add to the care plan?
Correct Answer: C
Rationale: Impaired skin integrity' fits a Stage IV ulcer. Deep damage e.g., bone exposed defines this e.g., 20% incidence unlike 'enhanced nutrition' , positive e.g., not current. 'Mobility' is risk e.g., not diagnosis. 'Chronic pain' may coexist e.g., not primary. A nurse adds e.g., Impaired integrity' per NANDA, a physiological focus. The text links Stage IV to skin loss, making the correct, specific diagnosis.