ATI LPN
Skin Integrity and Wound Care Questions Questions
Question 1 of 5
Upon reassessment, which Braden score will be the best sign that the risk for skin breakdown is removed for a patient with an initial score of 15?
Correct Answer: D
Rationale: The Braden Scale (6-23) predicts pressure ulcer risk; higher scores indicate lower risk. A score of 23 (Choice D), per the text, is perfect, showing no deficits in sensory perception, moisture, activity, mobility, nutrition, or friction/shear eliminating breakdown risk. Scores of 12 and 13 signal high risk. A score of 20 is good but not optimal. From 15 (moderate risk), achieving 23 confirms all interventions succeeded, making this the correct sign for nurses to aim for.
Question 2 of 5
When the nurse is caring for a patient with a Penrose drain, what care needs to be carried out?
Correct Answer: C
Rationale: Penrose drains are open, unsutured, and not connected to suction, requiring care to avoid dislodgement.
Question 3 of 5
When discussing stage 3 pressure ulcers with the student nurse, which description would the staff nurse include?
Correct Answer: B
Rationale: Stage 3 ulcers extend into subcutaneous tissue but not through fascia, and may include tunneling.
Question 4 of 5
Which item should the nurse use first to assist in staging an ulcer on the heel of a darkly pigmented skin patient?
Correct Answer: D
Rationale: Staging in darkly pigmented skin requires clear visualization. Natural light , per the flashcards, is the first tool, enhancing inspection by avoiding fluorescent distortion, revealing subtle erythema or discoloration. Measuring tape sizes later. Cotton applicators assess depth post-staging. Gloves ensure sterility but don't aid visibility. Accurate initial assessment, per nursing protocols, hinges on lighting to differentiate stages (e.g., Stage I vs. II), making this the correct first item.
Question 5 of 5
Which nursing observation will indicate the wound healed by secondary intention?
Correct Answer: D
Rationale: Secondary intention, per the flashcards, results in severe scarring as open wounds fill with scar tissue, often impairing function. Options A-C are missing, but minimal scarring or redness don't fit. Nurses observe this in burns or ulcers, noting prolonged healing and infection risk, making this the correct indicator.