ATI LPN
Skin Integrity and Wound Care NCLEX Questions Questions
Question 1 of 5
Which laboratory data will be important for the nurse to check for a patient who has developed a pressure ulcer?
Correct Answer: C
Rationale: Albumin reflects nutritional status critical for wound healing, per the text, with low levels (<3.5 g/dL) indicating malnutrition a pressure ulcer risk. Vitamin E isn't key. Potassium and sodium affect electrolytes, not healing directly. Nurses monitor albumin (and prealbumin) to ensure protein supports tissue repair, making this the correct lab data to check.
Question 2 of 5
Which score will the nurse document for a patient with slight sensory impairment, rarely moist skin, occasional walking, slightly limited mobility, excellent meal intake, and no friction/shear issues using the Braden Scale?
Correct Answer: C
Rationale: Braden Scale scores (6-23) assess risk; lower means higher risk. Per the text: slight sensory impairment (3), rarely moist (4), walks occasionally (3), slightly limited mobility (3), excellent intake (4), no friction/shear (4) total 20 (Choice C). This reflects moderate risk, making it the correct score.
Question 3 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 4 of 5
Which intervention should be included when the nurse is cleansing a wound site?
Correct Answer: C
Rationale: Wound cleansing prevents contamination spread. Cleansing from the least contaminated area (Choice C), per the text, directs solution outward from the wound to surrounding skin, maintaining sterility. Flowing from most to least contaminated risks infection. Vigorous scrubbing damages tissue, even with noncytotoxic solutions like saline. Clean gauze/gloves are standard but not the key intervention. This method protects healing tissue, aligning with infection control principles, making it the correct inclusion.
Question 5 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.