ATI LPN
Skin Integrity NCLEX Questions Questions
Question 1 of 5
Which nursing diagnosis does the nurse add to the care plan for a patient with a Stage IV pressure ulcer?
Correct Answer: C
Rationale: Stage IV ulcers involve severe skin loss, warranting 'Impaired skin integrity' (Choice C), per NANDA-I, reflecting the primary issue. Enhanced nutrition is a goal, not diagnosis. Mobility and pain may coexist but aren't central. This diagnosis drives wound care, making it the correct addition.
Question 2 of 5
Which action should the nurse take to assist with pain management for a postoperative medial meniscus repair of the right knee?
Correct Answer: D
Rationale: Ice (Choice D), per the text, reduces edema, bleeding, and pain post-knee surgery by numbing the area and constricting vessels. Vital signs monitor status but don't relieve pain. Checking pulses assesses circulation, not pain. A dependent leg increases swelling, worsening pain. Ice is a direct, evidence-based intervention nurses use alongside analgesics, making this the correct action for pain management.
Question 3 of 5
The nurse is caring for a postoperative patient who has had abdominal surgery and whose wound has completely eviscerated when the nurse walks into the room. In addition to notifying the surgeon, what should the nurse do?
Correct Answer: D
Rationale: Moist saline gauze prevents drying and further damage in evisceration until surgical intervention.
Question 4 of 5
The nurse knows that a hydrocolloid dressing is appropriate for use on which type of wound?
Correct Answer: D
Rationale: Hydrocolloids absorb moderate drainage and form a gel, unsuitable for heavy drainage or tunneling.
Question 5 of 5
The nurse knows what goal to be appropriate for a patient with a stage 3 pressure ulcer with the nursing diagnosis impaired physical mobility?
Correct Answer: C
Rationale: Assisting with position changes addresses impaired mobility directly.