ATI RN
NCLEX Questions on Skin Integrity and Wound Care Questions
Question 1 of 5
Which is the priority nursing assessment for a patient wearing an abdominal binder after abdominal surgery?
Correct Answer: C
Rationale: For an abdominal binder post-surgery, 'lung sounds and pulse oximetry' are priority, per Potter's *Essentials*. Binders support incisions e.g., 10 cm long but tight fit risks breathing e.g., SpO2 drops 5% unlike 'mental status' , unaffected e.g., no brain link. 'Fluids' track hydration e.g., not binder-related. 'Pedal pulses' check circulation e.g., legs, not abdomen. A nurse listens e.g., Clear, 95%' ensuring ventilation (e.g., 80% of binder risks), a physiological integrity must. Potter stresses respiratory monitoring, making the correct, top assessment.
Question 2 of 5
The nurse is caring for a patient in the burn unit. Which type of wound healing will the nurse consider when planning care for this patient?
Correct Answer: B
Rationale: Burns heal by 'secondary intention'. Tissue loss e.g., 3rd-degree fills with scar e.g., weeks unlike 'partial-thickness' , epidermal e.g., minor burns. 'Tertiary intention' delays e.g., not typical. 'Primary intention' is closed e.g., surgery. A nurse plans e.g., Moist dressings' per 60% burn cases, a physiological need. The text notes secondary's slow, infection-prone path, making the correct, open healing type.
Question 3 of 5
A patient presents to the emergency department with a laceration of the right forearm caused by a fall. After determining that the patient is stable, what is the next best step for the nurse to take?
Correct Answer: B
Rationale: After stability, 'inspect the wound for bleeding' is next. Lacerations bleed e.g., 50 mL needing control e.g., pressure unlike 'foreign bodies' , later e.g., post-hemostasis. 'Size' follows e.g., for sutures. 'Tetanus' is last e.g., history-based. A nurse checks e.g., Active bleed' per 90% of trauma protocol, a physiological must. The text prioritizes bleeding, making the correct, urgent step.
Question 4 of 5
The nurse is caring for a patient with a Stage IV pressure ulcer. Which nursing diagnosis does the nurse add to the care plan?
Correct Answer: C
Rationale: Impaired skin integrity' fits a Stage IV ulcer. Deep damage e.g., bone exposed defines this e.g., 20% incidence unlike 'enhanced nutrition' , positive e.g., not current. 'Mobility' is risk e.g., not diagnosis. 'Chronic pain' may coexist e.g., not primary. A nurse adds e.g., Impaired integrity' per NANDA, a physiological focus. The text links Stage IV to skin loss, making the correct, specific diagnosis.
Question 5 of 5
The nurse is caring for a patient who is immobile and is at risk for skin impairment. The plan of care includes turning the patient. Which is the best method for repositioning the patient?
Correct Answer: B
Rationale: Utilize a transfer device to lift the patient' is best. Lifting e.g., slide sheet cuts shear e.g., 30% less friction unlike '30-degree supine' , mispositioned e.g., not lateral. 'Elevate 45 degrees' risks ulcers e.g., >30° shear. 'Slide' drags e.g., 40% injury. A nurse uses e.g., Lift to 30° lateral' per 80% protocol, a physiological must. The text favors lifting, making the correct, safe method.