ATI LPN
Skin Integrity and Wound Care NCLEX Questions Quizlet Questions
Question 1 of 5
The registered nurse is observing a newly hired nurse perform a dressing change on a client with a leg ulcer. An enzymatic agent is being used to treat the ulcer. Which observation, if made by the registered nurse, would indicate a need for further teaching with the newly hired nurse?
Correct Answer: B
Rationale: Enzymatic agents need moisture. Wrapping with gauze , per wound care protocols, traps the agent, risking healthy tissue damage; it should stay exposed or loosely covered. Saline cleansing and necrosis application are correct. Open air aligns with use. Further teaching ensures debridement efficacy, making this the incorrect action.
Question 2 of 5
A nurse is evaluating a client's response to negative pressure wound therapy (NPWT). Which outcome indicates that the therapy is effective?
Correct Answer: A
Rationale: Decreased edema in the wound area is the correct answer, as it shows negative pressure wound therapy (NPWT) is working effectively. NPWT applies suction to remove excess fluid, reducing swelling, improving circulation, and fostering a healing environment by decreasing edema. Increased drainage would suggest NPWT isn't managing fluid properly, as it should reduce, not increase, exudate. Decreased granulation tissue indicates poor healing, as NPWT aims to boost this tissue's growth, not diminish it. Increased eschar reflects failure, as NPWT should aid debridement, not promote necrotic tissue buildup. Reduced edema aligns with NPWT's mechanism enhancing blood flow and fluid removal making it a clear indicator of success in supporting wound recovery.
Question 3 of 5
A client is admitted to the hospital with a diabetic foot ulcer. The nurse notes that the wound has a black, dry, and hard eschar covering most of its surface. Which action should the nurse take?
Correct Answer: D
Rationale: Consulting with the provider about surgical debridement is the correct action for a diabetic foot ulcer with black, dry, hard eschar. Eschar indicates significant necrotic tissue, which delays healing and heightens infection risk in diabetic patients, who are prone to complications due to poor vascularity and immune response. Surgical debridement swiftly removes this barrier, exposing viable tissue for healing, and is the most efficient method for extensive necrosis. Wet-to-dry dressings are outdated and inappropriate for dry eschar, as they're better for moist slough and can harm healthy tissue. Transparent film traps moisture but doesn't address necrosis, risking infection beneath the eschar. Leaving it open to air invites contamination and drying, slowing recovery. Given the wound's severity and diabetes context, consulting for surgical intervention ensures timely, effective management, reducing risks like osteomyelitis or amputation.
Question 4 of 5
A nurse is assessing a client with a pressure ulcer on the sacrum. Which finding should the nurse report to the provider immediately?
Correct Answer: A
Rationale: Foul odor and purulent drainage is the correct finding to report immediately, as it signals an acute infection in the pressure ulcer. This combination suggests bacterial proliferation, potentially leading to sepsis or deeper tissue damage, requiring urgent provider intervention, wound culture, and possibly antibiotics. Black, necrotic tissue indicates eschar, which needs debridement but isn't immediately life-threatening unless unstable or infected, manageable by the wound team. Red, granulating tissue is a healthy sign of healing, not a concern. Yellow, sloughing tissue represents slough, which delays healing but isn't an emergency unless paired with infection signs. The foul odor and purulent drainage escalate the situation to critical, demanding prompt reporting to prevent systemic complications, distinguishing it as the priority among these findings.
Question 5 of 5
A client has a stage 3 pressure ulcer on the left trochanter with moderate serosanguineous drainage. The wound is $4 cm in length, $3 cm in width, and $2 cm in depth. The wound bed is $80% granulation tissue and $20% slough. Which type of dressing should the nurse use for this wound?
Correct Answer: C
Rationale: Alginate is the correct dressing for a stage 3 pressure ulcer with moderate serosanguineous drainage, depth, and mixed tissue. Derived from seaweed, alginate absorbs moderate to heavy exudate (up to 20 times its weight), forming a gel that maintains moisture, supports autolytic debridement of the 20% slough, and fills the 2 cm depth, promoting healing. Hydrocolloid suits minimal drainage, risking maceration in deeper, exudative wounds. Hydrogel hydrates dry wounds but can't handle moderate drainage, potentially leaking. Transparent film is non-absorbent, unfit for exudate or depth, and better for superficial wounds. Alginate's absorbency and adaptability make it ideal for this wound's characteristics, balancing moisture and clearing debris effectively.