ATI LPN
Skin Integrity and Wound Care NCLEX Questions 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 increases pressure ulcer risk by exposing skin to moisture, bacteria, and enzymes, causing maceration and breakdown, per nursing principles. Eating two-thirds of breakfast suggests some nutrition, not a risk indicator. A red rash on the shin is concerning but not a high-risk pressure area like the sacrum or heels. Normal capillary refill indicates good circulation, not risk. Moisture from incontinence softens skin, amplifying pressure effects, making this the key observation nurses note for early intervention, aligning with risk assessment tools like Braden.
Question 2 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 3 of 5
Which action should the nurse take first when changing a dressing on a wound with a drain?
Correct Answer: A
Rationale: Dressing changes cause pain. Providing analgesics 30 minutes prior (Choice A), per the text, eases discomfort, enhancing patient cooperation. Avoiding drain removal and gloves follow. Gathering supplies is preparatory. Pain management sets the stage for a smooth procedure, making this the correct first action.
Question 4 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 5 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.