ATI LPN
Skin Integrity and Wound Care Questions Questions
Question 1 of 5
Which is the best method for repositioning an immobile patient to decrease the formation of pressure ulcers?
Correct Answer: B
Rationale: Repositioning reduces shear and friction. Using a transfer device to lift (Choice B), per the text, prevents dragging, which damages skin layers in immobile patients. A 30-degree supine position misaligns with the recommended 30-degree lateral tilt to offload pressure points. Elevating the bed 45 degrees increases shear risk, not reduces it. Sliding causes friction, worsening skin stress. Lifting with devices like slide sheets or hoists is evidence-based, minimizing trauma and ensuring safe pressure relief every 2 hours, making this the correct method for nurses to implement.
Question 2 of 5
The nurse identifies what goal to be the most appropriate goal for a patient with a stage 3 pressure ulcer who has a Nursing diagnosis of Impaired skin integrity?
Correct Answer: B
Rationale: Stage 3 ulcers take time to heal; showing signs of healing in 2 weeks is realistic.
Question 3 of 5
When the nurse is caring for a patient with a Penrose drain, what care needs to be carried out?
Correct Answer: C
Rationale: Penrose drains are open, unsutured, and not connected to suction, requiring care to avoid dislodgement.
Question 4 of 5
When discussing stage 3 pressure ulcers with the student nurse, which description would the staff nurse include?
Correct Answer: B
Rationale: Stage 3 ulcers extend into subcutaneous tissue but not through fascia, and may include tunneling.
Question 5 of 5
Which item should the nurse use first to assist in staging an ulcer on the heel of a darkly pigmented skin patient?
Correct Answer: D
Rationale: Staging in darkly pigmented skin requires clear visualization. Natural light , per the flashcards, is the first tool, enhancing inspection by avoiding fluorescent distortion, revealing subtle erythema or discoloration. Measuring tape sizes later. Cotton applicators assess depth post-staging. Gloves ensure sterility but don't aid visibility. Accurate initial assessment, per nursing protocols, hinges on lighting to differentiate stages (e.g., Stage I vs. II), making this the correct first item.