ATI RN
NCLEX Skin Integrity Questions Questions
Question 1 of 5
The patient's sacral pressure injury is open with exposed bone. Which pressure injury stage will be recorded in the patient's chart?
Correct Answer: D
Rationale: A sacral injury with exposed bone is 'Stage 4' , per Potter's *Essentials* and NPUAP. Full-thickness loss e.g., bone visible 2 cm deep may include tunneling, unlike 'Stage 1' , nonblanchable redness e.g., intact skin. 'Stage 2' is partial-thickness e.g., shallow ulcer, no bone. 'Stage 3' is full-thickness e.g., fat visible, not bone. A nurse charting e.g., Bone at sacrum' notes Stage 4's severity (e.g., 20% of sacral ulcers), needing debridement. Potter defines Stage 4 as deepest damage, distinct from Stage 3's limit at subcutaneous fat, a physiological integrity key. is the correct, advanced stage.
Question 2 of 5
The patient just sustained a deep laceration that is bleeding profusely. Which stage of healing describes the current state of the patient's wound?
Correct Answer: A
Rationale: A fresh, bleeding laceration is in 'hemostasis phase' , per Potter's. Clotting e.g., platelets seal in 5 minutes stops blood e.g., 100 mL loss unlike 'proliferative' , tissue growth e.g., day 3. 'Inflammation' cleans e.g., next 2 days. 'Remodeling' scars e.g., months later. A nurse sees e.g., Clot forming' hemostasis's 100% start, per healing science, a physiological must. Potter marks this as bleeding control, making the correct, immediate stage.
Question 3 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 4 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 5 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.