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 separation of wound layers often presents with a patient sensing 'something has given way' (Choice C), per the text, especially after strain like coughing. Organ protrusion is evisceration, a later stage. Chronic drainage or purulent drainage may signal infection, not dehiscence directly. This patient report prompts urgent nurse assessment, making it the correct alert for potential dehiscence.
Question 2 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 3 of 5
Which health care team member will the nurse consult for a patient with impaired skin integrity?
Correct Answer: B
Rationale: Nutrition aids healing. A registered dietitian (Choice B), per the text, optimizes calories and protein for skin integrity, critical for pressure ulcers. Respiratory therapists address breathing. Case managers plan discharge. Chaplains offer spiritual support. Dietitian collaboration enhances recovery, making this the correct consult.
Question 4 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 5 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.