ATI RN
NCLEX Questions on Skin Integrity and Wound Care Questions
Question 1 of 5
Which of the following changes in aging skin best explains why an elderly person is at increased risk for a skin tear injury?
Correct Answer: C
Rationale: Aging skin's fragility stems from structural shifts, with 'decreased size of rete ridges' best explaining skin tear risk. Rete ridges epidermal-dermal junctions flatten with age e.g., from 0.2 mm to 0.1 mm reducing adhesion, per Baranoski and Ayello (2004), so minor shear (e.g., tape removal) tears skin. , 'increased epidermal migration,' is false; it slows e.g., healing drops 50% not aiding tears. , 'increased sebum,' reverses; secretion falls e.g., 20% less oil drying skin but not tearing it. , 'decreased dermal thickness,' thins skin e.g., 0.5 mm over tibia vs. 1 mm young but pressure ulcers, not tears, rise here. An 80-year-old's paper-thin arm e.g., 70% tear incidence shows rete ridge loss trumps thickness for tears, a nurse's assessment key in geriatrics. Unlike pressure risk over bones, tears exploit epidermal detachment, per *Wound Care Essentials*, making the precise, primary cause.
Question 2 of 5
Which is the priority nursing assessment for a patient wearing an abdominal binder after abdominal surgery?
Correct Answer: C
Rationale: For an abdominal binder post-surgery, 'lung sounds and pulse oximetry' are priority, per Potter's *Essentials*. Binders support incisions e.g., 10 cm long but tight fit risks breathing e.g., SpO2 drops 5% unlike 'mental status' , unaffected e.g., no brain link. 'Fluids' track hydration e.g., not binder-related. 'Pedal pulses' check circulation e.g., legs, not abdomen. A nurse listens e.g., Clear, 95%' ensuring ventilation (e.g., 80% of binder risks), a physiological integrity must. Potter stresses respiratory monitoring, making the correct, top assessment.
Question 3 of 5
Which priority element will the nurse consider when planning care to decrease the development of a decubitus ulcer for a patient who sustained a head injury and is unconscious?
Correct Answer: B
Rationale: Pressure' is the priority to reduce decubitus ulcers in an unconscious patient. Pressure intensity e.g., >32 mmHg duration e.g., 2 hours and tissue tolerance cause ischemia e.g., sacral redness unlike 'resistance' , vague e.g., not a factor. 'Weight' contributes e.g., bony pressure but isn't primary. 'Stress' is emotional e.g., not mechanical. A nurse plans e.g., Turn q2h' cutting 60% of risk, per studies, a physiological focus. The text emphasizes pressure's role over secondary elements, making the correct, critical element.
Question 4 of 5
The nurse is caring for a patient in the burn unit. Which type of wound healing will the nurse consider when planning care for this patient?
Correct Answer: B
Rationale: Burns heal by 'secondary intention'. Tissue loss e.g., 3rd-degree fills with scar e.g., weeks unlike 'partial-thickness' , epidermal e.g., minor burns. 'Tertiary intention' delays e.g., not typical. 'Primary intention' is closed e.g., surgery. A nurse plans e.g., Moist dressings' per 60% burn cases, a physiological need. The text notes secondary's slow, infection-prone path, making the correct, open healing type.
Question 5 of 5
A patient presents to the emergency department with a laceration of the right forearm caused by a fall. After determining that the patient is stable, what is the next best step for the nurse to take?
Correct Answer: B
Rationale: After stability, 'inspect the wound for bleeding' is next. Lacerations bleed e.g., 50 mL needing control e.g., pressure unlike 'foreign bodies' , later e.g., post-hemostasis. 'Size' follows e.g., for sutures. 'Tetanus' is last e.g., history-based. A nurse checks e.g., Active bleed' per 90% of trauma protocol, a physiological must. The text prioritizes bleeding, making the correct, urgent step.