ATI LPN
Skin Integrity and Wound Care NCLEX Questions Quizlet Questions
Question 1 of 5
Which initial action should the nurse take to decrease the risk of skin impairment for a patient with residual mobility problems after a stroke?
Correct Answer: A
Rationale: Skin integrity begins with basic care. Using gentle cleansers and thorough drying (Choice A), reduces irritation and moisture key risks for a stroke patient with limited mobility. Harsh soaps disrupt skin barriers, and wet skin fosters maceration, both accelerating breakdown over bony prominences. Therapeutic beds help but are secondary, addressing pressure after skin protection. Absorbent pads are controversial, used only if other options fail, as they may trap moisture. Products holding moisture worsen risk, opposite to prevention goals. Gentle cleansing and drying are foundational, proactive steps nurses take first to maintain skin health, aligning with evidence-based practice and making this the correct initial action.
Question 2 of 5
The nurse is caring for a patient who is postoperative day one from an abdominal surgery. When the patient complains of a 'popping sensation' and a wetness in the dressing, the nurse immediately suspects which complication?
Correct Answer: C
Rationale: Wound dehiscence is the separation of tissue layers, often with a popping sensation and wetness, an emergency situation.
Question 3 of 5
The nurse is explaining the purpose of occlusive dressings to the student nurse. Which statement by the student nurse indicates a lack of understanding?
Correct Answer: C
Rationale: Occlusive dressings are contraindicated in infected wounds, indicating a misunderstanding.
Question 4 of 5
The nurse is performing a wet/damp to dry dressing change when the patient begins to complain of severe pain. What does the nurse do first?
Correct Answer: C
Rationale: Stopping the procedure addresses immediate pain, allowing further assessment.
Question 5 of 5
Which nursing observation will indicate the patient is at risk for pressure ulcer formation?
Correct Answer: A
Rationale: Fecal incontinence signals risk, per nursing standards, by exposing skin to moisture and enzymes, softening it for breakdown (maceration). The flashcards list this as a key observation, as prolonged contact with stool rich in bacteria amplifies pressure effects on areas like the coccyx. Eating two-thirds of breakfast suggests some nutrition, not a risk factor. Options C and D are missing, but the context implies fecal incontinence's prominence. Nurses note this in risk assessments (e.g., Braden's moisture subscale), prompting interventions like cleansing and barriers, making this the correct observation.