ATI LPN
Skin Integrity NCLEX Questions Questions
Question 1 of 5
The wound care nurse is monitoring a patient with a Stage III pressure ulcer whose wound presents with healthy tissue. How should the nurse document this ulcer in the patient's medical record?
Correct Answer: C
Rationale: A Stage III ulcer, with full-thickness loss to fat, retains its stage even as it heals. Healing Stage III' , per the flashcards, reflects healthy tissue (e.g., granulation) while preserving original staging for accuracy and care continuity. Stage I is intact skin, not applicable. Healing Stage II underestimates depth. Stage III alone omits healing progress. Proper documentation, per NPUAP guidelines, informs treatment (e.g., moist dressings) and reimbursement, making this the correct choice for nurses.
Question 2 of 5
Upon entering the room of a patient with a healing Stage III pressure ulcer, the nurse notices an odor and observes a purulent discharge, along with increased redness at the wound site. What action should the nurse give priority to?
Correct Answer: A
Rationale: Signs of infection (odor, pus, redness) require a full assessment , per the flashcards, gathering vitals, labs (e.g., WBC), and treatment data before escalation. Notification follows. Consulting wound care or charge nurse is secondary. Comprehensive data informs care, making this the correct priority.
Question 3 of 5
The nurse caring for a patient with a pressure ulcer on the left hip that is black. Which next step will the nurse anticipate?
Correct Answer: C
Rationale: Black tissue is necrotic, requiring debridement (implied Choice C), per nursing standards, to remove infection and aid healing. Options are missing, but monitoring or drainage aren't next. Nurses anticipate this, making it the correct step.
Question 4 of 5
The nurse documents 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: Nonblanchable redness indicates poor perfusion, fitting Ineffective peripheral tissue perfusion' , per the flashcards. Nutrition , infection , and pain don't match. This targets circulation, making it the correct diagnosis.
Question 5 of 5
The nurse is caring for a patient at risk for skin impairment. Which initial action should the nurse take to decrease this risk?
Correct Answer: A
Rationale: Skin protection is first. Thorough drying after cleansing , per the flashcards, prevents moisture-related breakdown. Beds and pads are secondary. Moisture-retaining products increase risk. This foundational step aligns with nursing prevention, making it the correct initial action.