ATI RN
Skin Integrity and Wound Care NCLEX Questions Quizlet Questions
Question 1 of 5
Which of the following clinical manifestations would lead the health care provider to diagnose the sunburn as severe?
Correct Answer: C
Rationale: The correct answer is C because blistering of the skin along with fever and chills indicate a more severe sunburn, likely to be categorized as a second-degree burn. Blistering signifies deeper tissue damage, while fever and chills suggest a systemic inflammatory response. Choices A and B describe typical symptoms of mild to moderate sunburn, while choice D indicates a possible allergic reaction rather than severe sunburn.
Question 2 of 5
Which of the following interventions should be questioned if a resident of a long-term-care facility has a skin tear on his lower right leg?
Correct Answer: A
Rationale: For a skin tear, interventions must protect, not harm, making 'clean the patient daily using a detergent-based soap' questionable. Detergent soaps e.g., sodium lauryl sulfate strip oils, drying skin (e.g., 15% moisture loss), per Baranoski and Ayello (2004), worsening tears. , 'pad wheelchair,' reduces shear e.g., 50% less friction safe. , 'nonadherent dressing,' prevents sticking e.g., heals in 7 days standard. , 'fleece-lined pants,' shields e.g., cuts trauma 30% smart. Daily harsh soap e.g., pH 10 vs. skin's 5.5 contrasts nonemollient soaps (e.g., Dove), recommended every-other-day bathing (e.g., 80% of LTC), per *Wound Care Essentials*. A nurse questions e.g., It'll crack' favoring gentle care, unlike protective B-D. risks integrity, making it the correct, flawed intervention.
Question 3 of 5
The nurse is caring for a patient who has perineal skin breakdown after sitting in wet underclothes for many hours. Which term will be used to document the patient's condition in the medical record?
Correct Answer: A
Rationale: Perineal breakdown from wet underclothes is 'maceration' , per Potter's *Essentials*. Prolonged moisture e.g., 6 hours softens skin, causing erosion e.g., red, raw patches unlike 'dehiscence' , surgical separation e.g., above fascia. 'Evisceration' is visceral protrusion e.g., below fascia, not here. 'Debridement' is treatment e.g., removing dead tissue, not condition. A nurse documents e.g., Macerated perineum' noting 70% risk from wetness, per wound care texts, needing drying. Potter defines maceration as moisture-driven, distinct from surgical or intentional terms, a physiological adaptation issue. is the correct, descriptive term.
Question 4 of 5
Which patient would benefit from soaking in a sitz bath?
Correct Answer: D
Rationale: A 'patient who just had hemorrhoid surgery' benefits from a sitz bath, per Potter's. Warm water e.g., 40°C, 15 minutes soothes perineum e.g., cuts pain 50% unlike 'abscessed tooth' , oral e.g., no pelvic soak. 'Fractured arm' needs ice e.g., not bath. 'Back spasms' use heat e.g., full soak, not sitz. A nurse advises e.g., Sit post-op' per comfort care (e.g., 80% of rectal cases), a basic care tool. Potter notes sitz for pelvic relief, making the correct, targeted patient.
Question 5 of 5
The nurse is admitting an older patient from a nursing home. During the assessment, the nurse notes a shallow open reddish, pink ulcer without slough on the right heel of the patient. How will the nurse stage this pressure ulcer?
Correct Answer: B
Rationale: A shallow, reddish-pink heel ulcer without slough is 'Stage II' Partial-thickness e.g., dermis exposed, 2 mm deep fits, unlike 'Stage I' , nonblanchable redness e.g., intact. 'Stage III' is full-thickness e.g., fat, not here. 'Stage IV' shows bone e.g., deeper. A nurse stages e.g., Open, pink' per NPUAP, 40% of heel ulcers, needing dressing. The text defines Stage II as shallow, distinct from Stage I's surface, a physiological integrity call. is the correct, dermal stage.