ATI RN
Skin Integrity and Wound Care NCLEX Questions Quizlet Questions
Question 1 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 2 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 3 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.
Question 4 of 5
A nurse is caring for a postoperative patient. Which finding will alert the nurse to a potential wound dehiscence?
Correct Answer: C
Rationale: A patient's report of 'something has given way' alerts to dehiscence. Skin layers parting e.g., post-cough feels sudden e.g., 5% risk unlike 'organ protrusion' , evisceration e.g., deeper. 'Chronic drainage' hints e.g., not definitive. 'Purulent drainage' is infection e.g., not separation. A nurse assesses e.g., Felt pop' per surgical strain, a physiological red flag. The text ties this sensation to dehiscence, making the correct, early sign.
Question 5 of 5
The nurse is caring for a patient who has a Stage IV pressure ulcer with grafted surgical sites. Which specialty bed will the nurse use for this patient?
Correct Answer: B
Rationale: For Stage IV with grafts, an 'air-fluidized' bed is best. Fluid-like support e.g., air through beads redistributes pressure e.g., <15 mmHg unlike 'low-air-loss' , moisture control e.g., not graft-specific. 'Lateral rotation' aids lungs e.g., not skin. 'Standard mattress' risks e.g., 32 mmHg. A nurse uses e.g., Air-fluidized for grafts' per 70% graft success, a physiological must. The text specifies this for surgical sites, making the correct, optimal bed.