ATI RN
NCLEX Questions Skin Integrity and Wound Care Questions
Question 1 of 5
Which goal will the nurse include in Aaron's plan of care?
Correct Answer: A
Rationale: The correct answer is A because maintaining intact skin is a priority in nursing care to prevent skin breakdown and pressure ulcers. This goal ensures the client's overall health and quality of life. Choice B is incorrect as restoring motor function may not be a priority depending on the client's condition. Choice C is incorrect as client teaching is important but not the primary goal in this scenario. Choice D is incorrect as preventing impaired skin integrity is not as effective as ensuring the skin remains intact.
Question 2 of 5
The nurse is caring for a client who is being discharged following abdominal surgery with an incision. Which instruction is most important for the nurse to teach this client regarding wound healing?
Correct Answer: D
Rationale: The correct answer is D because it emphasizes the importance of monitoring for signs of infection, such as swelling, warmth, or tenderness, which are crucial in detecting complications early. This instruction ensures prompt medical intervention if needed, promoting proper wound healing. A: Thoroughly irrigating the wound with hydrogen peroxide once a day can be too harsh and may delay healing by damaging healthy tissue. B: Applying a lubricating lotion to the edges of the wound may not address infection risk or proper wound care. C: Adding more fruits and vegetables to the diet is beneficial for overall health but not directly related to wound healing or preventing complications.
Question 3 of 5
Which client should the nurse anticipate will have the greatest psychosocial needs?
Correct Answer: D
Rationale: The correct answer is D because a client in isolation typically has limited social interaction, leading to increased feelings of loneliness, anxiety, and depression. Isolation can have a significant impact on psychosocial well-being. In contrast, clients under standard precautions (Choice A) and droplet precautions (Choice C) can still have regular social interactions. Choice B, a client taking antibiotics, does not directly correlate with increased psychosocial needs. In summary, clients in isolation are more likely to have greater psychosocial needs compared to the other options.
Question 4 of 5
On which region of the body would the nurse most expect to observe erysipelas?
Correct Answer: B
Rationale: The correct answer is B: Ankles. Erysipelas is a bacterial skin infection typically caused by Streptococcus bacteria. The lower extremities, especially the ankles, are common sites for erysipelas due to factors like compromised circulation and skin trauma increasing susceptibility. Erysipelas presents with well-defined, raised, and erythematous patches on the skin, commonly seen on the lower legs and ankles. The infection usually affects the superficial layers of the skin and subcutaneous tissues, leading to characteristic symptoms such as warmth, pain, and swelling in the affected area. Choices A, C, and D are incorrect as erysipelas typically occurs on the lower extremities rather than the abdomen, neck, or back.
Question 5 of 5
The nurse is assessing a client who presents with purulent drainage and crusting of the eye. The nurse should recognize that these findings are most consistent with which type of infection?
Correct Answer: C
Rationale: The correct answer is C: Bacterial conjunctivitis. Purulent drainage and crusting of the eye are indicative of a bacterial infection. Bacterial conjunctivitis typically presents with these symptoms due to the bacterial presence causing inflammation and discharge. Viral conjunctivitis (A) may have watery discharge, while allergic conjunctivitis (B) is characterized by itching and clear discharge. Fungal conjunctivitis (D) is rare and usually presents with a slow onset and may involve a white patch on the eye.