ATI LPN
Skin Integrity and Wound Care NCLEX Questions Quizlet Questions
Question 1 of 5
Which action will the nurse take next if a wound drain's collection device shows a sudden decrease in drainage?
Correct Answer: A
Rationale: A sudden drainage drop suggests blockage (Choice A), per the text, requiring provider notification for intervention. Charting delays action. Compression doesn't confirm patency. Nurses don't remove drains (Choice D). Prompt reporting prevents complications like fluid buildup, making this the correct next step.
Question 2 of 5
Which initial action should the nurse take to decrease the risk of skin impairment for a patient with residual mobility problems after a stroke?
Correct Answer: A
Rationale: Skin integrity begins with basic care. Using gentle cleansers and thorough drying (Choice A), reduces irritation and moisture key risks for a stroke patient with limited mobility. Harsh soaps disrupt skin barriers, and wet skin fosters maceration, both accelerating breakdown over bony prominences. Therapeutic beds help but are secondary, addressing pressure after skin protection. Absorbent pads are controversial, used only if other options fail, as they may trap moisture. Products holding moisture worsen risk, opposite to prevention goals. Gentle cleansing and drying are foundational, proactive steps nurses take first to maintain skin health, aligning with evidence-based practice and making this the correct initial action.
Question 3 of 5
Which is the best explanation for the nurse to use when teaching a patient the reason for an abdominal binder after an open abdominal aortic aneurysm repair?
Correct Answer: D
Rationale: An abdominal binder supports the large incision post-aortic repair (Choice D), per the text, stabilizing it during movement or coughing to promote healing and reduce strain. Reducing edema is secondary, more relevant to extremities. Securing dressings is a minor role. Immobilization applies to sprains, not this context. Support enhances patient comfort and wound integrity, making this the correct explanation for nurses to provide.
Question 4 of 5
The nurse is caring for a patient who is postoperative day one from an abdominal surgery. When the patient complains of a 'popping sensation' and a wetness in the dressing, the nurse immediately suspects which complication?
Correct Answer: C
Rationale: Wound dehiscence is the separation of tissue layers, often with a popping sensation and wetness, an emergency situation.
Question 5 of 5
The nurse is explaining the purpose of occlusive dressings to the student nurse. Which statement by the student nurse indicates a lack of understanding?
Correct Answer: C
Rationale: Occlusive dressings are contraindicated in infected wounds, indicating a misunderstanding.