ATI LPN
Skin Integrity and Wound Care NCLEX Questions Quizlet 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 risk, per nursing standards, by exposing skin to moisture and enzymes, softening it for breakdown (maceration). The flashcards list this as a key observation, as prolonged contact with stool rich in bacteria amplifies pressure effects on areas like the coccyx. Eating two-thirds of breakfast suggests some nutrition, not a risk factor. Options C and D are missing, but the context implies fecal incontinence's prominence. Nurses note this in risk assessments (e.g., Braden's moisture subscale), prompting interventions like cleansing and barriers, making this the correct observation.
Question 2 of 5
A nurse is caring for a patient with a wound. Which assessment data will be most relevant with regard to wound healing?
Correct Answer: B
Rationale: Pulse oximetry , per the flashcards, assesses oxygen saturation crucial for wound healing, as hypoxia delays repair. Muscular strength aids mobility, not healing directly. Options C and D are missing. Nurses ensure oxygenation (>90%) supports cellular repair, making this the correct data.
Question 3 of 5
The nurse is caring for a patient who has a Stage IV pressure ulcer with grafted surgical sites. Which specialty bed will the nurse use for this patient?
Correct Answer: B
Rationale: Air-fluidized beds , per the flashcards, redistribute pressure via immersion, protecting Stage IV grafts. Low-air-loss prevents moisture. Lateral rotation aids lungs. Standard mattresses lack support. This bed optimizes healing, making it the correct choice.
Question 4 of 5
The nurse is caring for a patient with a Stage IV pressure ulcer. Which nursing diagnosis should the nurse add to the care plan?
Correct Answer: C
Rationale: Stage IV ulcers warrant Impaired skin integrity' , per NANDA-I, as the primary issue, per the flashcards. Nutrition is a goal. Mobility and pain may coexist. This drives wound care, making it the correct diagnosis.
Question 5 of 5
The nurse is performing a moist-to-dry dressing. In which order will the nurse implement the steps, starting with the first one? (1. Apply sterile gloves, 2. Cover and secure topper dressing, 3. Assess wound and surrounding skin, 4. Moisten gauze with prescribed solution, 5. Gently wring out excess solution and unfold, 6. Loosely pack until all wound surfaces are in contact with gauze)
Correct Answer: B
Rationale: Moist-to-dry dressing sequence, per nursing practice, starts with sterile gloves (1) for infection control , then assesses wound (3), moistens gauze (4), wrings out (5), packs (6), and secures (2). Starting with moistening (Choices A, C) skips sterility. Moistening before assessing is illogical. This order ensures safety and efficacy, making it the correct sequence.