ATI LPN
NCLEX Questions Skin Integrity and Wound Care Questions
Question 1 of 5
Which finding will alert the nurse to a potential wound dehiscence in a postoperative patient?
Correct Answer: C
Rationale: Dehiscence wound layer separation often presents with a patient feeling something has given way' , per the flashcards, especially post-strain (e.g., coughing). Options A, B, and D are incomplete, but organ protrusion (evisceration) or drainage differ. This report triggers urgent nurse assessment, making it the correct alert.
Question 2 of 5
The nurse is completing a skin risk assessment using the Braden Scale. The patient has slight sensory impairment, has skin that is rarely moist, walks occasionally, and has slightly limited mobility, along with excellent intake of meals and no apparent problem with friction and shear. Which score will the nurse document for this patient?
Correct Answer: C
Rationale: Braden scores (6-23) assess risk; higher is better. Per the flashcards: slight sensory (3), rarely moist (4), walks occasionally (3), slight mobility (3), excellent intake (4), no friction/shear (4) = 20 . This is moderate risk, making it the correct score.
Question 3 of 5
The nurse is caring for a patient with a Stage II pressure ulcer and has assigned a nursing diagnosis of Risk for infection. The patient is unconscious and bedridden. Which is the best goal for this patient?
Correct Answer: D
Rationale: Measurable goals suit unconscious patients. Remain free of odorous or purulent drainage' , per the flashcards, indicates no infection. Stating signs isn't possible. Family actions (Choices B, C) are interventions. This reflects prevention, making it the correct goal.
Question 4 of 5
The nurse leaves a pressure ulcer open to air and does not apply a dressing. Which stage pressure ulcer does this patient have?
Correct Answer: A
Rationale: Stage I ulcers intact, red heal without dressings , per the flashcards, resolving in 7-14 days with relief. Stage II , III , and IV need dressings for deeper damage. Open-to-air suits Stage I, making this the correct stage.
Question 5 of 5
Which action should the nurse take to meet the nutritional needs of a Jewish client?
Correct Answer: B
Rationale: Culturally sensitive care respects individual beliefs. Asking the client about dietary preferences ensures the nurse addresses specific Jewish dietary laws (e.g., kosher), which vary (e.g., avoiding pork or mixing dairy and meat). Ordering a kosher meal assumes uniformity, risking oversight of personal variations. Paper plates are irrelevant to nutrition. Consulting a dietitian is secondary without client input. Per nursing principles, understanding the client's needs first fosters trust and tailors care, aligning with transcultural models like Leininger's, making this the correct action.