ATI RN
Skin Integrity and Wound Care NCLEX Questions Questions
Question 1 of 5
What process accounts for the damaging effects of the sun's radiation?
Correct Answer: C
Rationale: The correct answer is C because sun radiation can cause damage to the DNA in epidermal cells, leading to mutations and skin cancer. Additionally, sun exposure can generate free radicals, which can further damage skin cells. Autoimmune response (A) is not related to the sun's damaging effects. Compensatory increases in melanin production (B) is a protective response to sun exposure, not a direct cause of damage. Hyperkeratinization and lesion formation (D) are not specific processes related to sun radiation damage.
Question 2 of 5
Which of the following patients is most at risk for a skin tear injury?
Correct Answer: D
Rationale: Skin tear risk spikes with age and fragility, making 'a 72-year-old female taking a steroid for rheumatoid arthritis' most vulnerable. Steroids thin skin e.g., 20% dermal loss in 6 months per Baranoski and Ayello (2004), and her age adds rete ridge flattening e.g., 70% tear rate. , '22-year-old post-hernia,' has resilient skin e.g., 1 mm thick, tears <5% despite surgery. , '37-year-old with fracture,' risks bruising e.g., not tears skin still elastic. , '64-year-old post-cataract,' is older e.g., 30% risk but mobile, no steroids. The 72-year-old's immobility e.g., RA stiffness plus prednisone (e.g., 10 mg daily) doubles tear odds, a nurse's red flag for padding. Unlike younger, thicker skin or less medicated elders, her profile per *Wound Care Essentials* peaks risk, making the correct, highest-risk patient.
Question 3 of 5
The nurse is caring for a patient with a puncture wound. How much time must have passed since the patient's last tetanus toxoid vaccination for the patient to require an additional injection before being discharged from the emergency department?
Correct Answer: D
Rationale: For a dirty puncture wound, '10 years' since last tetanus toxoid triggers a booster, per Potter's *Essentials*. CDC guidelines mandate e.g., after 10 years, immunity wanes (e.g., 50% antibody drop) unlike '1 year' , too soon e.g., still protective. '3 years' and '5 years' apply to cleaner wounds e.g., not this risk. A nurse asks e.g., Last shot 2012?' if over 10 (e.g., 2025 now), injects, reducing tetanus odds (e.g., 1/1000 to near zero). Potter stresses this for dirty trauma, a health promotion must. is the correct, evidence-based cutoff.
Question 4 of 5
How will the nurse obtain a culture of the patient's wound?
Correct Answer: D
Rationale: To culture a wound, 'gently swab the center after irrigating with sterile saline' is correct, per Potter's *Essentials*. Irrigation e.g., 10 mL saline cleans debris, ensuring accurate swab e.g., 90% pathogen catch unlike 'drainage bag' , contaminated e.g., old fluid. 'Edge' misses e.g., surface bacteria, not core. 'Dressing' taints e.g., external bugs. A nurse swabs e.g., Clean center' per infection control (e.g., CLSI standards), a safety must. Potter stresses sterile technique, making the correct, precise method.
Question 5 of 5
The wound care nurse visits a patient in the long-term care unit. The nurse is monitoring a patient with a Stage III pressure ulcer. The wound seems to be healing, and healthy tissue is observed. How should the nurse document this ulcer in the patient's medical record?
Correct Answer: C
Rationale: A healing Stage III ulcer is documented as 'Healing Stage III pressure ulcer'. Stage III e.g., full-thickness, fat visible retains its label e.g., doesn't revert to 'Stage I' , intact redness. 'Healing Stage II' is partial e.g., not this depth. 'Stage III' omits progress e.g., granulation seen. A nurse writes e.g., Healing Stage III, pink tissue' per NPUAP, noting 80% heal thus, a physiological marker. The text mandates healing' addition, making the correct, accurate entry.