ATI LPN
Skin Integrity and Wound Care NCLEX Questions Questions
Question 1 of 5
The patient is prescribed antiembolism stockings before discharge and asks, 'Why do I need these?' The best response would be:
Correct Answer: B
Rationale: Antiembolism stockings prevent DVT by aiding circulation.'They prevent clots' explains purpose clearly, per patient education standards. Surgeon's order avoids reasoning. Massage misrepresents function. Upset deflects. Accurate explanation empowers understanding, an LPN role, making it the correct and best response.
Question 2 of 5
In determining the patient's perception of pain, which question would be useful?
Correct Answer: C
Rationale: Pain perception is subjective.'How would you describe your pain?' captures quality (e.g., sharp), per PQRST assessment, guiding care. Location and history inform but don't define perception. Activity is context, not feeling. Description shapes treatment, an LPN tool, making it the correct question.
Question 3 of 5
Before you administer an opioid analgesic, the most important nursing action is to:
Correct Answer: D
Rationale: Opioids risk respiratory depression. Assessing respirations ensures safety rate <12/min signals danger, per pharmacology. BP is secondary. Comfort measures delay meds. Constipation is later. Breathing is the priority, an LPN check, making it the correct action.
Question 4 of 5
Which nursing observation will indicate the patient is at risk for pressure ulcer formation?
Correct Answer: A
Rationale: Fecal incontinence increases pressure ulcer risk by exposing skin to moisture, bacteria, and enzymes, causing maceration and breakdown, per nursing principles. Eating two-thirds of breakfast suggests some nutrition, not a risk indicator. A red rash on the shin is concerning but not a high-risk pressure area like the sacrum or heels. Normal capillary refill indicates good circulation, not risk. Moisture from incontinence softens skin, amplifying pressure effects, making this the key observation nurses note for early intervention, aligning with risk assessment tools like Braden.
Question 5 of 5
Which type of tissue will the nurse expect to observe when a wound is healing by full-thickness repair?
Correct Answer: C
Rationale: Full-thickness repair, as in Stage IV ulcers, progresses with granulation tissue red, moist, vascular tissue signaling healing, per the text. Eschar is necrotic, blocking healing. Slough is dead tissue needing removal. Purulent drainage indicates infection, not progress. Granulation marks the proliferative phase, a positive sign nurses monitor, guiding dressing choices like hydrogels, making this the correct tissue expected in healing.