ATI LPN
Skin Integrity and Wound Care Questions Questions
Question 1 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 2 of 5
Upon reassessment, which Braden score will be the best sign that the risk for skin breakdown is removed for a patient with an initial score of 15?
Correct Answer: D
Rationale: The Braden Scale (6-23) predicts pressure ulcer risk; higher scores indicate lower risk. A score of 23 (Choice D), per the text, is perfect, showing no deficits in sensory perception, moisture, activity, mobility, nutrition, or friction/shear eliminating breakdown risk. Scores of 12 and 13 signal high risk. A score of 20 is good but not optimal. From 15 (moderate risk), achieving 23 confirms all interventions succeeded, making this the correct sign for nurses to aim for.
Question 3 of 5
The nurse identifies what goal to be the most appropriate goal for a patient with a stage 3 pressure ulcer who has a Nursing diagnosis of Impaired skin integrity?
Correct Answer: B
Rationale: Stage 3 ulcers take time to heal; showing signs of healing in 2 weeks is realistic.
Question 4 of 5
When the nurse is caring for a patient with a Penrose drain, what care needs to be carried out?
Correct Answer: C
Rationale: Penrose drains are open, unsutured, and not connected to suction, requiring care to avoid dislodgement.
Question 5 of 5
When discussing stage 3 pressure ulcers with the student nurse, which description would the staff nurse include?
Correct Answer: B
Rationale: Stage 3 ulcers extend into subcutaneous tissue but not through fascia, and may include tunneling.