ATI LPN
NCLEX Practice Questions Skin Integrity and Wound Care Questions
Question 1 of 5
Which health care provider's order will the nurse question for a clean, granulating Stage III pressure ulcer?
Correct Answer: B
Rationale: Dakin's solution is cytotoxic, harming granulation tissue, per the text, and should be questioned for a clean Stage III ulcer. Low-air-loss and hydrogel support healing. Dietitian consults aid nutrition. Noncytotoxic saline is preferred, making this the correct order to challenge.
Question 2 of 5
A nurse leaves a pressure ulcer open to air without a dressing. To which patient did the nurse provide care?
Correct Answer: A
Rationale: Stage I pressure ulcers intact skin with nonblanchable redness heal without dressings (Choice A), per the text, resolving in 7-14 days with pressure relief. Stage II requires moisture-retentive dressings like hydrocolloids for partial-thickness loss. Stage III and IV need advanced dressings (e.g., hydrogels) for deeper damage. Open-to-air is appropriate only for Stage I, as it avoids unnecessary intervention while promoting natural recovery, making this the correct patient for the nurse's care approach.
Question 3 of 5
The nurse knows which description would be classified as a closed wound?
Correct Answer: A
Rationale: In a closed wound, like a bruise, the skin remains intact, unlike open wounds with breaks in the skin.
Question 4 of 5
A new nurse is delegating care of a chronic, nonsterile wound to a UAP. What action by the new nurse causes the preceptor to intervene?
Correct Answer: A
Rationale: Wound assessment is a nursing responsibility and cannot be delegated to UAP.
Question 5 of 5
The nurse is educating the patient about the use of heat/cold therapy at home. Which statement by the patient indicates the need for further education?
Correct Answer: C
Rationale: Hot packs should not be microwaved unless designed for it, indicating a need for clarification.