ATI LPN
Skin Integrity and Wound Care Questions Questions
Question 1 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 2 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.
Question 3 of 5
The nurse is completing an assessment on a patient who has a Stage IV pressure ulcer. The wound is odorous with a drain in place. Which statement by the patient indicates issues with self-concept?
Correct Answer: C
Rationale: Self-concept ties to body image. ' I really need a bath, I feel so awful' , per the flashcards, reflects shame over odor, impacting esteem. Weakness is physical. Going home and dinner are neutral. Nurses address this emotional cue, making it the correct statement.
Question 4 of 5
The nurse caring for a patient with a healing Stage III pressure ulcer notes that the wound is clean and granulating. Which health care provider's order will the nurse question?
Correct Answer: B
Rationale: Dakin's solution , per the flashcards, is cytotoxic, harming clean granulation tissue, and should be questioned. Low-air-loss , hydrogel , and dietitian consults support healing. Nurses advocate for saline, making this the correct order to challenge.
Question 5 of 5
The nurse is caring for a patient who is immobile and wants to decrease the formation of pressure ulcers. Which action will the nurse take first?
Correct Answer: C
Rationale: Prevention starts with assessment. Determining risk factors , per the flashcards, identifies vulnerabilities for tailored care. Fluids and nutrition support later. Turning follows risk ID. This ensures effective planning, making it the correct first action.