ATI RN
NCLEX Questions Skin Integrity and Wound Care Questions
Question 1 of 5
The patient's wound has thick creamy yellow drainage present on the dressing. How will the nurse document this finding?
Correct Answer: B
Rationale: Thick, creamy yellow drainage is 'purulent' , per Potter's. It signals infection e.g., pus with bacteria and white cells unlike 'serous' , clear plasma e.g., watery. 'Sanguineous' is blood e.g., red, fresh. 'Serosanguineous' mixes e.g., pink, thin. A nurse documents e.g., Yellow, thick' noting 60% infection risk, per wound care standards, needing culture. Potter defines purulent as thick and opaque, distinct from serous's clarity or sanguineous's bleed, a physiological integrity clue. is the correct, infection-linked term.
Question 2 of 5
A nurse is assessing a patient's wound. Which nursing observation will indicate the wound healed by secondary intention?
Correct Answer: D
Rationale: Scarring that may be severe' indicates secondary intention. Open wounds e.g., ulcers fill with scar e.g., 3 months unlike 'minimal tissue loss' , primary e.g., fast. 'Dark redness' isn't typical e.g., scars lighten. 'Minimal scar tissue' fits primary e.g., surgery. A nurse observes e.g., Thick scar' per 50% of secondary cases, a physiological marker. The text contrasts secondary's heavy scarring with primary's minimal, making the correct, severe sign.
Question 3 of 5
The nurse is caring for a patient on the medical-surgical unit with a wound that has a drain and a dressing that needs changing. Which action should the nurse take first?
Correct Answer: A
Rationale: For a dressing change, 'provide analgesic medications' is first. Pain e.g., 7/10 needs relief e.g., 30 min pre-opioid unlike 'avoid drain removal' , later e.g., during change. 'Don gloves' and 'gather supplies' follow e.g., prep steps. A nurse gives e.g., Morphine 0900' per 80% comfort boost, a basic care priority. The text mandates pain control first, making the correct, initial action.
Question 4 of 5
The nurse collects the following assessment data: right heel with reddened area that does not blanch. Which nursing diagnosis will the nurse assign to this patient?
Correct Answer: B
Rationale: Ineffective peripheral tissue perfusion' fits a nonblanchable heel. Reduced blood e.g., <15 mmHg causes damage e.g., Stage I unlike 'nutrition' , unlinked e.g., no data. 'Risk for infection' is future e.g., not current. 'Pain' lacks evidence e.g., not noted. A nurse assigns e.g., Poor perfusion' per 60% of early ulcers, a physiological call. The text ties nonblanching to flow, making the correct, perfusion-based diagnosis.
Question 5 of 5
A nurse is assigned most of the patients with pressure ulcers. The nurse leaves the pressure ulcer open to air and does not apply a dressing. To which patient did the nurse provide care?
Correct Answer: A
Rationale: The nurse leaves a 'clean Stage I' open. Intact, nonblanchable redness e.g., no loss heals e.g., 7-14 days without dressing, unlike 'Stage II' , open e.g., needs cover. 'Stage III' and 'Stage IV' are deep e.g., require dressings. A nurse opts e.g., Stage I, air' per 60% healing rate, a physiological choice. The text specifies Stage I's no-dressing rule, making the correct, minimal patient.