ATI LPN
Skin Integrity NCLEX Questions Questions
Question 1 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 2 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 3 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.
Question 4 of 5
Which is the best explanation for the nurse to provide when teaching the patient the reason for the binder after an open abdominal aortic aneurysm repair?
Correct Answer: D
Rationale: A binder supports the incision , per the flashcards, aiding healing during movement. Edema reduction is secondary. Dressing security is minor. Immobilization fits other contexts. This explanation clarifies purpose, making it the correct choice.
Question 5 of 5
Which action should the nurse take to communicate with a client from a culture that is different from their own?
Correct Answer: C
Rationale: Cross-cultural communication requires sensitivity. Paying attention to nonverbal cues , per nursing texts, decodes comfort or distress (e.g., gestures, posture) when verbal language differs. Touch or closeness may offend some cultures (e.g., high-context ones valuing space). Forcing eye contact ignores norms (e.g., respect via averted gaze in some groups). Nonverbal focus builds rapport safely, making this the correct action.