ATI RN
Skin Integrity and Wound Care Questions Questions
Question 1 of 5
Which factor contributes to pressure injury formation when patient's body slides downward to the foot of the bed?
Correct Answer: D
Rationale: Shearing force' drives pressure injury when a patient slides down in bed, per Potter's *Essentials*. Shear occurs as skin sticks to sheets while bones slide e.g., elevating head 30° pulls skeleton down 10 cm tearing capillaries, unlike 'momentum' , motion's force e.g., a rolling ball, not skin-specific. 'Acceleration' is speed gain e.g., falling, not sliding. 'Applied force' is generic e.g., pushing, not shear's dual-plane action. A nurse sees e.g., sacral redness after 2 hours shear's friction (e.g., 40% of bedbound cases), needing repositioning. Potter notes gravity's pull against stationary skin doubles injury risk vs. pressure alone, a reduction-of-risk focus. is the correct, mechanistic factor.
Question 2 of 5
Which assessment charting indicates that the wound is healing by primary intention?
Correct Answer: A
Rationale: The 4-inch incision edges are well approximated with intact sutures' shows primary intention, per Potter's *Essentials*. Clean closure e.g., sutured within 6 hours heals fast e.g., 7 days unlike 'ulcer with slough' , secondary e.g., open, slow. 'Deep incision with granulation' is secondary e.g., fills in. 'Abrasion' is superficial e.g., not sutured. A nurse charts e.g., Edges tight' primary's 80% rate, per surgical norms, a physiological marker. Potter contrasts with secondary's gap, making the correct, primary sign.
Question 3 of 5
The nurse is caring for a patient with a Stage IV pressure ulcer. Which type of healing will the nurse consider when planning care for this patient?
Correct Answer: B
Rationale: A Stage IV ulcer requires 'full-thickness wound repair'. Deep loss e.g., bone exposed heals via scar e.g., 4 phases: hemostasis to maturation unlike 'partial-thickness' , epidermal e.g., Stage II. 'Primary intention' is surgical e.g., closed fast. 'Tertiary intention' delays closure e.g., not typical. A nurse plans e.g., Debride, pack' per 20% Stage IV rate, a physiological focus. The text ties Stage IV to full repair, making the correct, deep healing type.
Question 4 of 5
A nurse is caring for a patient with a wound. Which assessment data will be most important for the nurse to gather with regard to wound healing?
Correct Answer: B
Rationale: Pulse oximetry assessment' is most critical for wound healing. Oxygen saturation e.g., 95% fuels repair e.g., collagen needs 20 mmHg unlike 'muscular strength' , mobility e.g., not direct. 'Sensation' checks nerves e.g., not oxygen. 'Sleep' aids rest e.g., indirect. A nurse measures e.g., SpO2 88%' per 30% healing delay risk, needing O2 therapy. The text ties perfusion to healing, a physiological priority, making the correct, vital data.
Question 5 of 5
The nurse is caring for a patient with a healing Stage III pressure ulcer. The wound is clean and granulating. Which health care provider's order will the nurse question?
Correct Answer: B
Rationale: The nurse questions 'irrigate with Dakin's solution' for a clean, granulating Stage III ulcer. Cytotoxic Dakin's e.g., kills fibroblasts harms healing e.g., 30% delay unlike 'low-air-loss' , pressure relief e.g., safe. 'Hydrogel' moistens e.g., 50% faster healing. 'Dietitian' boosts nutrition e.g., protein. A nurse asks e.g., Why Dakin's?' per noncytotoxic saline norm, a physiological integrity issue. The text bans cytotoxics on granulation, making the correct, questionable order.