The patient has a nonblanchable area of redness on the right malleolus. Which pressure injury stage will be recorded in the patient's chart?

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NCLEX Practice Questions Skin Integrity and Wound Care Questions

Question 1 of 5

The patient has a nonblanchable area of redness on the right malleolus. Which pressure injury stage will be recorded in the patient's chart?

Correct Answer: A

Rationale: A nonblanchable red area on the malleolus is 'Stage 1' , per Potter's *Essentials*. Intact skin with persistent erythema e.g., no lightening after 10 seconds marks early injury, unlike 'Stage 2' , partial-thickness e.g., open blister. 'Stage 3' is full-thickness e.g., fat exposed, not here. 'Stage 4' shows bone e.g., deep loss, not redness. A nurse records e.g., Malleolus red, intact' Stage 1's 60% progression risk, per NPUAP, needing padding. Potter notes Stage 1 as first warning, distinct from Stage 2's dermal breach, a physiological assessment staple. is the correct, initial stage.

Question 2 of 5

The nurse is working on a medical-surgical unit that has been participating in a research project associated with pressure ulcers. Which risk factor will the nurse assess for that predisposes a patient to pressure ulcer development?

Correct Answer: A

Rationale: The nurse assesses 'decreased level of consciousness' as a key pressure ulcer risk. Confused or unconscious patients e.g., post-stroke can't shift to relieve pressure e.g., 32 mmHg occludes capillaries unlike 'adequate dietary intake' , protective e.g., protein aids tissue. 'Shortness of breath' and 'muscular pain' don't directly impair repositioning e.g., not Braden factors. A nurse checks e.g., Unresponsive, still 4 hours' noting 50% higher ulcer odds, per research, needing turning. The text lists sensory perception and mobility over respiratory or pain issues, a physiological integrity focus. is the correct, predisposing factor.

Question 3 of 5

The nurse is caring for a patient who has experienced a laparoscopic appendectomy. For which type of healing will the nurse focus the care plan?

Correct Answer: D

Rationale: A laparoscopic appendectomy heals by 'primary intention'. Small, closed incisions e.g., 1 cm approximate fast e.g., 7 days unlike 'partial-thickness' , shallow e.g., abrasions. 'Secondary intention' is open e.g., burns. 'Tertiary intention' delays e.g., infection risk. A nurse plans e.g., Suture care' per 90% of surgeries, a physiological focus. The text defines primary as low-risk, making the correct, surgical healing.

Question 4 of 5

The nurse is completing an assessment on a patient with a Stage IV pressure ulcer. The wound is odorous, and a drain is currently in place. Which statement by the patient indicates issues with self-concept?

Correct Answer: C

Rationale: I am ready for my bath and linen change right now since this is awful' shows self-concept issues, per *Fundamentals*. Odor e.g., from Stage IV hints shame e.g., 60% report distress unlike 'weak, tired' , physical e.g., not image. 'Ready to go home' is positive e.g., hope. 'Good dinner' is neutral e.g., appetite. A nurse hears e.g., Awful smell' per body image impact, a psychosocial focus. The text links odor to esteem, making the correct, self-concept clue.

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: Provide analgesic medication' is most important. Pain relief e.g., 5 mg morphine boosts mobility e.g., 70% more movement unlike 'explain risks' , education e.g., not ability. 'Turn q3h' is q2h e.g., passive. 'Sit in chair' helps e.g., not pain-specific. A nurse gives e.g., Meds pre-move' per comfort's role, a physiological need. The text ties pain control to action, making the correct, key intervention.

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