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 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.
Question 2 of 5
The nurse is completing an assessment on a patient who has a Stage IV pressure ulcer. The wound is odorous with a drain in place. Which statement by the patient indicates issues with self-concept?
Correct Answer: C
Rationale: Self-concept ties to body image. ' I really need a bath, I feel so awful' , per the flashcards, reflects shame over odor, impacting esteem. Weakness is physical. Going home and dinner are neutral. Nurses address this emotional cue, making it the correct statement.
Question 3 of 5
The nurse caring for a patient with a healing Stage III pressure ulcer notes that the wound is clean and granulating. Which health care provider's order will the nurse question?
Correct Answer: B
Rationale: Dakin's solution , per the flashcards, is cytotoxic, harming clean granulation tissue, and should be questioned. Low-air-loss , hydrogel , and dietitian consults support healing. Nurses advocate for saline, making this the correct order to challenge.
Question 4 of 5
The nurse is caring for a patient who is immobile and wants to decrease the formation of pressure ulcers. Which action will the nurse take first?
Correct Answer: C
Rationale: Prevention starts with assessment. Determining risk factors , per the flashcards, identifies vulnerabilities for tailored care. Fluids and nutrition support later. Turning follows risk ID. This ensures effective planning, making it the correct first action.
Question 5 of 5
A patient at risk for skin impairment is able to sit up in a chair. How long should the nurse schedule the patient to sit in the chair?
Correct Answer: A
Rationale: Sitting over 2 hours risks ischemia on ischial tuberosities. Less than 2 hours at a time , per the flashcards, balances mobility and safety. Total daily limits or 30-minute caps are impractical. Comfort-based ignores objective risk. This standard prevents ulcers, making it the correct duration.