ATI LPN
Skin Integrity and Wound Care NCLEX Questions Questions
Question 1 of 5
Which is the best goal for an unconscious, bedridden patient with a Stage II pressure ulcer and a nursing diagnosis of Risk for infection?
Correct Answer: D
Rationale: Goals must be measurable.'Remain free of odorous or purulent drainage' (Choice D), per the text, indicates no infection in an unconscious patient. Stating signs isn't feasible. Family actions (Choices B, C) are interventions, not goals. This outcome reflects infection prevention, making it the correct goal.
Question 2 of 5
The nurse identifies which type of wounds heal by tertiary intention?
Correct Answer: D
Rationale: Tertiary intention involves delayed closure after being left open, unlike primary (immediate closure) or secondary (healing from the bottom up) intention.
Question 3 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 4 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 5 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.