ATI LPN
Skin Integrity and Wound Care NCLEX Questions Questions
Question 1 of 5
Which intervention should be included when the nurse is cleansing a wound site?
Correct Answer: C
Rationale: Wound cleansing prevents contamination spread. Cleansing from the least contaminated area (Choice C), per the text, directs solution outward from the wound to surrounding skin, maintaining sterility. Flowing from most to least contaminated risks infection. Vigorous scrubbing damages tissue, even with noncytotoxic solutions like saline. Clean gauze/gloves are standard but not the key intervention. This method protects healing tissue, aligning with infection control principles, making it the correct inclusion.
Question 2 of 5
The nurse recognizes which intervention is not a form of mechanical debridement?
Correct Answer: D
Rationale: Enzymatic debridement uses topical agents, not mechanical means like wet-to-dry or whirlpools.
Question 3 of 5
The nurse understands which rationale to be appropriate for drying a wound after irrigation?
Correct Answer: C
Rationale: Drying prevents moisture-related skin breakdown, not infection or dressing adhesion.
Question 4 of 5
The nurse caring for an unconscious patient who was involved in an automobile accident 2 weeks ago will give priority to which element when planning care to decrease the development of a decubitus ulcer?
Correct Answer: B
Rationale: Pressure is the cornerstone of decubitus ulcer formation, per the flashcards, as sustained force occludes capillaries (15-32 mm Hg), causing tissue ischemia in unconscious patients unable to reposition. Care planning focuses on offloading via turning schedules or specialty beds. Resistance isn't a recognized element here. Weight influences pressure distribution but isn't the root cause. Stress affects general health, not skin integrity directly. Pressure's intensity and duration are modifiable, evidence-based targets nurses prioritize to prevent ulcers, especially in prolonged immobility, making this the correct element.
Question 5 of 5
The nurse is caring for a patient who is experiencing a full-thickness wound repair. Which type of tissue will the nurse expect to observe when the wound is healing?
Correct Answer: C
Rationale: Full-thickness repair produces granulation tissue red, vascular, moist indicating healing progress, per the flashcards. Eschar is necrotic, requiring removal. Slough is dead tissue, impeding repair. Purulent drainage signals infection. Nurses monitor granulation in the proliferative phase, guiding moist dressing use, making this the correct tissue expected.