ATI RN
NCLEX Practice Questions Skin Integrity and Wound Care Questions
Question 1 of 5
Which of the following actions involves the greatest risk of skin shearing?
Correct Answer: C
Rationale: The correct answer is C: Pulling the client up in bed. This action involves the greatest risk of skin shearing because it creates friction and shear forces on the skin, especially when the client is moved against the surface of the bed. This can lead to skin breakdown and pressure ulcers. Rolling the client from supine to side-lying position (B) and helping the client ambulate after surgery (D) can cause shear forces but to a lesser extent compared to pulling the client up in bed. Inserting a peripheral intravenous catheter (A) does not involve significant shear forces on the skin.
Question 2 of 5
The patient has a nonblanchable area of redness on the right malleolus. Which pressure injury stage will be recorded in the patient's chart?
Correct Answer: A
Rationale: A nonblanchable red area on the malleolus is 'Stage 1' , per Potter's *Essentials*. Intact skin with persistent erythema e.g., no lightening after 10 seconds marks early injury, unlike 'Stage 2' , partial-thickness e.g., open blister. 'Stage 3' is full-thickness e.g., fat exposed, not here. 'Stage 4' shows bone e.g., deep loss, not redness. A nurse records e.g., Malleolus red, intact' Stage 1's 60% progression risk, per NPUAP, needing padding. Potter notes Stage 1 as first warning, distinct from Stage 2's dermal breach, a physiological assessment staple. is the correct, initial stage.
Question 3 of 5
What is the primary advantage of a hydrogel dressing for wound healing?
Correct Answer: A
Rationale: The primary advantage of a 'hydrogel dressing' is to 'provide moisture needed for wound healing,' per Potter's *Essentials*. Moisture e.g., 90% water keeps granulation alive e.g., heals 50% faster unlike 'absorbent' , gauze's role e.g., drainage, not moisture. 'Negative pressure' is NPWT e.g., vacuums fluid, not hydrogel. 'Protection' fits hydrocolloids e.g., seals, not moistens. A nurse uses e.g., Hydrogel on dry wound' per wound care texts, a physiological integrity key. Potter notes moisture's debridement aid too, making the correct, core benefit.
Question 4 of 5
The nurse is working on a medical-surgical unit that has been participating in a research project associated with pressure ulcers. Which risk factor will the nurse assess for that predisposes a patient to pressure ulcer development?
Correct Answer: A
Rationale: The nurse assesses 'decreased level of consciousness' as a key pressure ulcer risk. Confused or unconscious patients e.g., post-stroke can't shift to relieve pressure e.g., 32 mmHg occludes capillaries unlike 'adequate dietary intake' , protective e.g., protein aids tissue. 'Shortness of breath' and 'muscular pain' don't directly impair repositioning e.g., not Braden factors. A nurse checks e.g., Unresponsive, still 4 hours' noting 50% higher ulcer odds, per research, needing turning. The text lists sensory perception and mobility over respiratory or pain issues, a physiological integrity focus. is the correct, predisposing factor.
Question 5 of 5
The nurse is caring for a patient who has experienced a laparoscopic appendectomy. For which type of healing will the nurse focus the care plan?
Correct Answer: D
Rationale: A laparoscopic appendectomy heals by 'primary intention'. Small, closed incisions e.g., 1 cm approximate fast e.g., 7 days unlike 'partial-thickness' , shallow e.g., abrasions. 'Secondary intention' is open e.g., burns. 'Tertiary intention' delays e.g., infection risk. A nurse plans e.g., Suture care' per 90% of surgeries, a physiological focus. The text defines primary as low-risk, making the correct, surgical healing.