ATI LPN
Skin Integrity NCLEX Questions Questions
Question 1 of 5
What is the next best step for the nurse upon noticing an odor and purulent discharge with increased redness at a healing Stage III pressure ulcer site?
Correct Answer: A
Rationale: Odor, purulent discharge, and redness suggest infection. Completing a full assessment vitals, treatment, labs gathers data for accurate reporting, per the text, before notifying providers. SBAR notification follows assessment. Consulting wound care or the charge nurse is secondary. Comprehensive data collection ensures informed care escalation, making this the correct next step.
Question 2 of 5
Which nursing diagnosis does the nurse add to the care plan for a patient with a Stage IV pressure ulcer?
Correct Answer: C
Rationale: Stage IV ulcers involve severe skin loss, warranting 'Impaired skin integrity' (Choice C), per NANDA-I, reflecting the primary issue. Enhanced nutrition is a goal, not diagnosis. Mobility and pain may coexist but aren't central. This diagnosis drives wound care, making it the correct addition.
Question 3 of 5
How long should the nurse schedule a patient at risk for skin impairment to sit in a chair?
Correct Answer: B
Rationale: Prolonged sitting increases pressure on ischial tuberosities, risking skin breakdown. Scheduling less than 2 hours (Choice B), per the text, limits ischemia, especially for at-risk patients, balancing mobility with safety. Over 3 hours exceeds safe pressure duration, per studies showing tissue damage after 2 hours. Thirty minutes is overly restrictive, reducing mobility benefits. Comfort-based duration ignores objective risk, as patients may not feel early damage. The 2-hour limit, often with cushions, is a standard nursing intervention to redistribute pressure, making this the correct choice for protecting skin integrity.
Question 4 of 5
Which action should the nurse take to assist with pain management for a postoperative medial meniscus repair of the right knee?
Correct Answer: D
Rationale: Ice (Choice D), per the text, reduces edema, bleeding, and pain post-knee surgery by numbing the area and constricting vessels. Vital signs monitor status but don't relieve pain. Checking pulses assesses circulation, not pain. A dependent leg increases swelling, worsening pain. Ice is a direct, evidence-based intervention nurses use alongside analgesics, making this the correct action for pain management.
Question 5 of 5
The nurse is caring for a postoperative patient who has had abdominal surgery and whose wound has completely eviscerated when the nurse walks into the room. In addition to notifying the surgeon, what should the nurse do?
Correct Answer: D
Rationale: Moist saline gauze prevents drying and further damage in evisceration until surgical intervention.