ATI RN
NCLEX Skin Integrity Questions Questions
Question 1 of 5
The patient's incision is fading to a pale pink following surgery 2 months previously. Which stage of the healing describes the current status of the patient's wound?
Correct Answer: B
Rationale: A pale pink incision 2 months post-surgery is in 'remodeling phase' , per Potter's. Collagen reorganizes e.g., scar strengthens 80% by 6 weeks unlike 'hemostasis' , initial bleeding stop e.g., minutes post-op. 'Proliferative' builds tissue e.g., days 3-21, red granulation. 'Inflammation' cleans e.g., first 3 days, swelling. A nurse assesses e.g., Faint scar' remodeling's 3-month span, per healing science, a physiological marker. Potter defines this as scar maturation, distinct from proliferative's growth, making the correct, late stage.
Question 2 of 5
The nurse is caring for a patient who is experiencing a full-thickness repair. Which type of tissue will the nurse expect to observe when the wound is healing?
Correct Answer: C
Rationale: In full-thickness repair, 'granulation' is expected. Red, moist tissue e.g., new vessels marks healing e.g., 2 weeks in unlike 'eschar' , black necrosis e.g., to remove. 'Slough' is yellow, dead e.g., blocks healing. 'Purulent drainage' signals infection e.g., delays. A nurse sees e.g., Pink, budding' per 70% of repairs, a physiological sign. The text ties granulation to progress, making the correct, healing tissue.
Question 3 of 5
The nurse is collaborating with the dietitian about a patient with a Stage III pressure ulcer. Which nutrient will the nurse most likely increase after collaboration with the dietitian?
Correct Answer: B
Rationale: Protein' is most likely increased for a Stage III ulcer. Healing needs e.g., 1.5 g/kg/day rebuild tissue e.g., 50% faster unlike 'fat' , energy e.g., not repair. 'Vitamin E' is minor e.g., not key. 'Carbohydrate' fuels e.g., not structure. A nurse plans e.g., Add 20 g protein' per nutritional guidelines, a physiological need. The text prioritizes protein with vitamins A/C, making the correct, essential nutrient.
Question 4 of 5
The nurse is completing a skin risk assessment using the Braden Scale. The patient has slight sensory impairment, has skin that is rarely moist, walks occasionally, and has slightly limited mobility, along with excellent intake of meals and no apparent problem with friction and shear. Which score will the nurse document for this patient?
Correct Answer: C
Rationale: The Braden score is '20'. Subscales: sensory (3, slight impairment), moisture (4, rarely moist), activity (3, walks occasionally), mobility (3, slightly limited), nutrition (4, excellent), friction/shear (4, no problem) total 20. '15' is high risk e.g., <16. '17' undercounts e.g., misses points. '23' is perfect e.g., not here. A nurse tallies e.g., 20, low risk' per 6-23 range, a physiological tool. The text matches this, making the correct, calculated score.
Question 5 of 5
The nurse is caring for a patient who has suffered a stroke and has residual mobility problems. The patient is at risk for skin impairment. Which initial actions should the nurse take to decrease this risk?
Correct Answer: A
Rationale: Use gentle cleansers, and thoroughly dry the skin' is the initial action. Nonionic surfactants e.g., pH 5.5 prevent breakdown e.g., 50% less risk unlike 'therapeutic bed' , secondary e.g., later cost. 'Absorbent pads' are last-resort e.g., controversial. 'Moisture-holding products' harm e.g., maceration. A nurse cleans e.g., Dry post-wash' per basic care, a physiological priority. The text starts with skin hygiene, making the correct, first step.