ATI RN
NCLEX Questions on Skin Integrity and Wound Care Questions
Question 1 of 5
Which action would be most helpful in preventing pressure ulcer formation in an at-risk client?
Correct Answer: A
Rationale: Repositioning every hour is the correct answer as it helps redistribute pressure, reducing the risk of pressure ulcer formation. This action prevents prolonged pressure on specific areas, improving blood flow and tissue oxygenation. Providing a low-protein diet (B) is incorrect as protein is essential for wound healing. Ensuring a generous fluid intake (C) is important for overall skin health but alone does not prevent pressure ulcers. Massaging reddened areas on the sacrum (D) can actually worsen skin damage by increasing friction and pressure on vulnerable skin.
Question 2 of 5
What is the purpose of a wet-to-dry dressing?
Correct Answer: A
Rationale: The purpose of a wet-to-dry dressing is to mechanically debride the tissue, which involves removing dead or infected tissue through the physical action of the dressing. First, the wet dressing helps to soften and loosen the necrotic tissue. Then, as the dressing dries, it adheres to the dead tissue and upon removal, it pulls the debris away, promoting a clean wound bed. This process facilitates wound healing by promoting tissue regeneration. Other choices are incorrect because reducing local tissue maceration and preventing bacterial growth are not the primary purposes of a wet-to-dry dressing. Additionally, preserving granulation tissue is not the intended goal of this dressing method.
Question 3 of 5
The nurse is assessing a client who is recovering following surgery. Which factor would increase this client's susceptibility to infection?
Correct Answer: B
Rationale: The presence of an incision increases the client's susceptibility to infection as it provides a direct entry point for pathogens. A breach in the skin barrier increases the risk of microbes entering the body and causing infection. Intact mucous membranes help protect against pathogens, making choice A incorrect. Dry skin may increase the risk of skin breakdown but does not directly impact susceptibility to infection. Active bowel sounds are indicative of bowel function and do not directly relate to susceptibility to infection, making choice D incorrect.
Question 4 of 5
Which agent can be used to destroy pathogens other than spores?
Correct Answer: B
Rationale: The correct answer is B: Disinfectant. Disinfectants are agents used to destroy pathogens on surfaces or objects, but they are not effective against spores. Antiseptics are used on living tissues, sterilizing agents eliminate all microorganisms including spores, and isolating agents do not destroy pathogens. Disinfectants are the best choice for destroying pathogens other than spores due to their effectiveness on surfaces.
Question 5 of 5
When providing care to a client with a wound, which evidence-based interventions should the nurse anticipate carrying out? Select the one that does not apply
Correct Answer: B
Rationale: The correct answer is B. Covering the wound only if a scab forms is not an evidence-based intervention because it can interfere with the natural healing process. Keeping the wound dry (A) helps prevent infection. Ensuring the wound remains moist (C) promotes healing. Keeping the wound covered (D) provides protection and maintains a moist environment. In summary, B is incorrect because covering the wound based on scab formation does not align with best practices for wound care.