ATI LPN
Skin Integrity NCLEX Questions Questions
Question 1 of 5
The registered nurse (RN) directs the licensed practical nurse (LPN) to assist with the care of a client who has a sacral pressure injury. Which is the most appropriate activity for the RN to delegate to the LPN?
Correct Answer: A
Rationale: LPN scope includes basic care. Positioning , per nursing delegation standards (e.g., NCSBN), suits LPN skills, aiding pressure relief. Initiating protocols or determining plans (Choice D, incomplete) require RN judgment. Meeting (Choice C, incomplete) is vague but likely RN-level. Delegation optimizes care safely, making this the most appropriate activity.
Question 2 of 5
A nurse is assessing a client with a pressure ulcer on the sacrum. Which finding indicates a potential complication of the wound?
Correct Answer: C
Rationale: Foul-smelling greenish discharge is the correct answer, indicating a potential complication such as infection in the pressure ulcer. This type of discharge, often linked to bacteria like Pseudomonas, combined with a foul odor, suggests microbial overgrowth that can hinder healing and lead to serious outcomes like sepsis if untreated. Prompt reporting and a wound culture are critical to identify the pathogen and tailor treatment. Serous drainage is typically clear and watery, a normal part of healing unless it becomes excessive or purulent. Redness and warmth around the wound are expected signs of inflammation and increased blood flow during early healing stages, not necessarily problematic unless accompanied by worsening symptoms. Granulation tissue is a healthy sign, showing new tissue growth and vascularization, not a complication. The distinct foul-smelling, greenish discharge stands out as an abnormal finding requiring immediate attention, distinguishing it from the other options.
Question 3 of 5
A nurse is preparing to change a dressing on a client's surgical incision. Which type of dressing should the nurse use to promote autolytic debridement of the wound?
Correct Answer: D
Rationale: Hydrogel dressing is the correct answer to promote autolytic debridement in a surgical incision. Autolytic debridement uses the body's enzymes and moisture to break down necrotic tissue, and hydrogel, being water- or glycerin-based, hydrates the wound, creating an ideal moist environment for this process. This is gentle and effective for incisions with minor necrosis or slough, preserving healthy tissue. Alginate dressing is absorbent and suited for heavy exudate, not dry or minimally draining wounds needing debridement. Foam dressing cushions and absorbs moderate exudate but doesn't hydrate enough for autolysis. Gauze dressing can dry out and stick, causing trauma upon removal, and lacks the moisture retention needed for autolytic action. Hydrogel's ability to donate moisture distinguishes it, supporting natural debridement while minimizing pain and disruption, making it the best choice for this healing mechanism.
Question 4 of 5
A client with venous insufficiency has a venous stasis ulcer on the lower leg. Which instruction should the nurse give to the client to promote wound healing?
Correct Answer: D
Rationale: All of the above,' is correct, as all listed instructions applying compression stockings or bandages , avoiding crossing legs or tight clothing , and keeping the leg elevated promote healing of a venous stasis ulcer. Venous insufficiency causes blood pooling, edema, and pressure, impairing wound recovery. Compression therapy enhances venous return, reducing swelling and supporting circulation. Avoiding leg crossing or tight garments prevents vessel constriction, maintaining blood flow. Elevation above heart level uses gravity to drain fluid, alleviating edema and pressure. Each action targets a facet of venous ulcer pathology, and together, they form a comprehensive strategy to improve oxygenation, reduce inflammation, and accelerate healing, making D the most inclusive and effective choice for patient education in this chronic condition.
Question 5 of 5
A nurse is caring for a client who has a venous leg ulcer on the lower left calf. The nurse notes that the wound has copious amounts of yellow-green purulent drainage with a foul odor. The periwound skin is erythematous, warm, and edematous. The client reports increased pain and fever. What should the nurse do first?
Correct Answer: B
Rationale: Obtaining a wound culture and sensitivity is the correct first action for a venous leg ulcer with yellow-green purulent drainage, foul odor, erythema, edema, pain, and fever all signs of infection. Identifying the pathogen via culture guides antibiotic therapy, addressing the root cause before complications like sepsis escalate, critical in venous ulcers with poor healing potential. Compression bandages aid venous return but are secondary until infection is managed, as pressure could worsen an active infection. Analgesics and antipyretics treat symptoms, not the infection, delaying essential diagnostics. Elevation reduces edema but doesn't tackle the infection directly. Culturing first ensures targeted treatment, aligning with priority-setting in wound care to resolve infection swiftly.