ATI LPN
NCLEX Questions Skin Integrity and Wound Care Questions
Question 1 of 5
Which assessment is the priority when completing a skin integrity assessment?
Correct Answer: A
Rationale: Pressure points (Choice A), like bony prominences, are the priority, per the text, as they're prone to ulcers. Breath (Choice B), bowel (Choice C), and pulse sounds inform overall status but aren't skin-specific. Visual/tactile checks at pressure sites detect early damage, making this the correct focus.
Question 2 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 3 of 5
The nurse is educating the patient about the signs and symptoms of a wound infection. Which statement indicates a need for further education?
Correct Answer: D
Rationale: All infected wounds show redness, warmth, and drainage (possibly pus) and require treatment; this statement is correct and doesn't indicate a need for further education, but the question implies misunderstanding, making D the least indicative of needing clarification.
Question 4 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 5 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.