ATI LPN
Skin Integrity and Wound Care Questions Questions
Question 1 of 5
Which item should the nurse use first to assist in staging an ulcer on a patient with darkly pigmented skin?
Correct Answer: D
Rationale: Staging ulcers in darkly pigmented skin requires accurate visualization. A halogen light is used first, per the text, to enhance inspection by countering fluorescent light's blue tones, revealing subtle redness or discoloration. Measuring tape sizes wounds later. Cotton applicators assess depth, not initial staging. Sterile gloves ensure infection control but don't aid visibility. Proper lighting is critical for the first step inspection ensuring nurses correctly identify stages like nonblanchable erythema, making this the correct initial tool.
Question 2 of 5
Which nutrient will the nurse most likely increase after collaboration with the dietitian for a patient with a Stage III pressure ulcer?
Correct Answer: B
Rationale: Protein is critical for wound healing, per the text, supporting collagen synthesis and tissue repair in Stage III ulcers. Fats and carbohydrates provide energy but aren't primary. Vitamin E isn't emphasized. Nurses and dietitians boost protein (e.g., 1.25-1.5 g/kg/day) to heal deep wounds, making this the correct nutrient to increase.
Question 3 of 5
Which next step will the nurse anticipate for a pressure ulcer that is black?
Correct Answer: C
Rationale: Black tissue is necrotic, requiring debridement (Choice C), per the text, to remove infection sources and promote healing. Monitoring delays care. Documentation follows action. Drainage isn't primary. Debridement clears the wound bed, making this the correct anticipated step.
Question 4 of 5
Which nursing diagnosis will the nurse assign to a patient with a reddened, nonblanchable area on the right heel?
Correct Answer: B
Rationale: Nonblanchable redness signals impaired blood flow, fitting 'Ineffective peripheral tissue perfusion' (Choice B), per the text, as oxygen delivery falters. Nutrition isn't indicated. Infection and pain may follow but aren't primary. This diagnosis targets circulation, making it the correct assignment.
Question 5 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.