ATI RN
NCLEX Questions Skin Integrity and Wound Care Questions
Question 1 of 5
Which nursing observation will indicate the patient is at risk for pressure ulcer formation?
Correct Answer: A
Rationale: Fecal incontinence' signals pressure ulcer risk. Moisture from stool e.g., 6 hours softens skin, causing maceration e.g., 70% breakdown rate unlike 'two thirds of breakfast' , neutral e.g., not malnutrition. 'Red rash on shin' isn't high-risk e.g., not bony. 'Capillary refill <2 seconds' is normal e.g., no ischemia. A nurse observes e.g., Soiled, wet' needing cleaning, per Braden moisture scale. The text ties moisture to injury over diet or circulation, a physiological integrity clue. is the correct, risk-indicating observation.
Question 2 of 5
The nurse is caring for a patient on the medical-surgical unit with a wound that has a drain and a dressing that needs changing. Which action should the nurse take first?
Correct Answer: A
Rationale: For a dressing change, 'provide analgesic medications' is first. Pain e.g., 7/10 needs relief e.g., 30 min pre-opioid unlike 'avoid drain removal' , later e.g., during change. 'Don gloves' and 'gather supplies' follow e.g., prep steps. A nurse gives e.g., Morphine 0900' per 80% comfort boost, a basic care priority. The text mandates pain control first, making the correct, initial action.
Question 3 of 5
The nurse collects the following assessment data: right heel with reddened area that does not blanch. Which nursing diagnosis will the nurse assign to this patient?
Correct Answer: B
Rationale: Ineffective peripheral tissue perfusion' fits a nonblanchable heel. Reduced blood e.g., <15 mmHg causes damage e.g., Stage I unlike 'nutrition' , unlinked e.g., no data. 'Risk for infection' is future e.g., not current. 'Pain' lacks evidence e.g., not noted. A nurse assigns e.g., Poor perfusion' per 60% of early ulcers, a physiological call. The text ties nonblanching to flow, making the correct, perfusion-based diagnosis.
Question 4 of 5
A nurse is assigned most of the patients with pressure ulcers. The nurse leaves the pressure ulcer open to air and does not apply a dressing. To which patient did the nurse provide care?
Correct Answer: A
Rationale: The nurse leaves a 'clean Stage I' open. Intact, nonblanchable redness e.g., no loss heals e.g., 7-14 days without dressing, unlike 'Stage II' , open e.g., needs cover. 'Stage III' and 'Stage IV' are deep e.g., require dressings. A nurse opts e.g., Stage I, air' per 60% healing rate, a physiological choice. The text specifies Stage I's no-dressing rule, making the correct, minimal patient.
Question 5 of 5
Which layer of the skin provides protection against bacteria, as well as chemical and mechanical injuries?
Correct Answer: A
Rationale: The 'epidermis' protects against bacteria and injuries, per ProProfs. As the outer layer e.g., 0.1 mm thick it's a tight cell barrier e.g., 98% pathogen block regenerating e.g., 28 days unlike 'dermis' , supportive e.g., 2 mm, vessels. 'Sebum layer' isn't a layer e.g., gland output. 'Subcutaneous layer' cushions e.g., fat, deeper. A nurse checks e.g., Surface shield' per immune cells like Langerhans, a physiological role. The quiz emphasizes its barrier function, making the correct, protective layer.