ATI LPN
NCLEX Questions Skin Integrity and Wound Care Questions
Question 1 of 5
Which action should the nurse take for a patient who appears anxious as the nurse prepares to change a wound dressing?
Correct Answer: B
Rationale: Anxiety during dressing changes stems from uncertainty. Explaining the procedure (Choice B), per the text, educates and involves the patient, reducing fear by giving control and predictability. Television distracts but doesn't address anxiety's root. Closing eyes avoids engagement, potentially increasing tension. Asking family to leave may isolate the patient, worsening distress if they're a support. Explanation aligns with therapeutic communication, calming the patient and aiding cooperation, making this the correct action for nurses to take.
Question 2 of 5
The nurse is repositioning the patient in the side-lying position. To avoid putting the patient at risk for pressure ulcers, the nurse should place the head of the bed in which position?
Correct Answer: C
Rationale: A 30-degree angle avoids direct pressure on bony prominences like the trochanter.
Question 3 of 5
The nurse identifies which syringe to use when irrigating a patient's deep wound?
Correct Answer: D
Rationale: A 30- to 50-mL syringe with an 18-gauge catheter provides the recommended 4-15 psi for deep wound irrigation.
Question 4 of 5
A nurse participating in a research project associated with pressure ulcers will assess for what predisposing factor that tends to increase the risk for pressure ulcer development?
Correct Answer: A
Rationale: Pressure ulcers arise from unrelieved pressure impairing tissue perfusion. Decreased level of consciousness heightens risk, per nursing principles, as patients can't sense or relieve pressure, aligning with Braden Scale's sensory perception category. These patients, often bedridden or confused, miss cues to shift positions, increasing ischemic damage over bony prominences like the sacrum. Adequate dietary intake supports healing, not risk. Shortness of breath impacts oxygenation but isn't a direct factor. Muscular pain may reduce mobility but isn't primary. Research prioritizes consciousness as a measurable, prevalent risk factor nurses assess, making this the correct choice.
Question 5 of 5
Which patient will the nurse see first?
Correct Answer: C
Rationale: Priority follows acuity. Appendicitis with a heating pad , per the flashcards, risks rupture an emergency outweighing a chronic Stage IV ulcer . A Braden score of 18 is low risk. An approximated incision is normal. Heat exacerbates inflammation, per nursing principles, demanding immediate nurse action to prevent peritonitis, making this the correct first patient.