ATI RN
NCLEX Skin Integrity Questions Questions
Question 1 of 5
Which of the following actions could result in pressure ulcer formation?
Correct Answer: A
Rationale: The correct answer is A because pulling a stroke client up in bed can create friction and shear forces on the skin, leading to pressure ulcer formation. This action puts pressure on vulnerable areas of the skin, especially if the client is immobile or has limited mobility. Turning a client from side to side every 2 hours (B) is actually a preventive measure to reduce pressure ulcer risk by redistributing pressure. Allowing a client to slide up in a chair at mealtime (C) may not directly contribute to pressure ulcers unless prolonged pressure is exerted. Applying powder to buttocks area when diaphoresis has become a problem (D) can help reduce moisture but is not a direct cause of pressure ulcers.
Question 2 of 5
The patient's sacral pressure injury is open with exposed bone. Which pressure injury stage will be recorded in the patient's chart?
Correct Answer: D
Rationale: A sacral injury with exposed bone is 'Stage 4' , per Potter's *Essentials* and NPUAP. Full-thickness loss e.g., bone visible 2 cm deep may include tunneling, unlike 'Stage 1' , nonblanchable redness e.g., intact skin. 'Stage 2' is partial-thickness e.g., shallow ulcer, no bone. 'Stage 3' is full-thickness e.g., fat visible, not bone. A nurse charting e.g., Bone at sacrum' notes Stage 4's severity (e.g., 20% of sacral ulcers), needing debridement. Potter defines Stage 4 as deepest damage, distinct from Stage 3's limit at subcutaneous fat, a physiological integrity key. is the correct, advanced stage.
Question 3 of 5
The patient's incision is fading to a pale pink following surgery 2 months previously. Which stage of the healing describes the current status of the patient's wound?
Correct Answer: B
Rationale: A pale pink incision 2 months post-surgery is in 'remodeling phase' , per Potter's. Collagen reorganizes e.g., scar strengthens 80% by 6 weeks unlike 'hemostasis' , initial bleeding stop e.g., minutes post-op. 'Proliferative' builds tissue e.g., days 3-21, red granulation. 'Inflammation' cleans e.g., first 3 days, swelling. A nurse assesses e.g., Faint scar' remodeling's 3-month span, per healing science, a physiological marker. Potter defines this as scar maturation, distinct from proliferative's growth, making the correct, late stage.
Question 4 of 5
The patient just sustained a deep laceration that is bleeding profusely. Which stage of healing describes the current state of the patient's wound?
Correct Answer: A
Rationale: A fresh, bleeding laceration is in 'hemostasis phase' , per Potter's. Clotting e.g., platelets seal in 5 minutes stops blood e.g., 100 mL loss unlike 'proliferative' , tissue growth e.g., day 3. 'Inflammation' cleans e.g., next 2 days. 'Remodeling' scars e.g., months later. A nurse sees e.g., Clot forming' hemostasis's 100% start, per healing science, a physiological must. Potter marks this as bleeding control, making the correct, immediate stage.
Question 5 of 5
The nurse is caring for a patient who is experiencing a full-thickness repair. Which type of tissue will the nurse expect to observe when the wound is healing?
Correct Answer: C
Rationale: In full-thickness repair, 'granulation' is expected. Red, moist tissue e.g., new vessels marks healing e.g., 2 weeks in unlike 'eschar' , black necrosis e.g., to remove. 'Slough' is yellow, dead e.g., blocks healing. 'Purulent drainage' signals infection e.g., delays. A nurse sees e.g., Pink, budding' per 70% of repairs, a physiological sign. The text ties granulation to progress, making the correct, healing tissue.