ATI LPN
NCLEX Questions Skin Integrity and Wound Care Questions
Question 1 of 5
Which of the following is the most appropriate comparison of process and outcome measures?
Correct Answer: D
Rationale: D Per the test, outcome measures like mortality need risk adjustment (e.g., age, comorbidities) for fair comparison across providers, unlike process measures (e.g., aspirin given), which track actions without adjustment. Process measures don't need large samples small audits suffice. Neither is less important ; both inform quality. Administrative databases often lack process details (e.g., timing), favoring outcomes like death. Risk adjustment ensures outcome validity, while process simplicity aids direct measurement, making this the correct comparison.
Question 2 of 5
A hospital is implementing clinical decision support to detect potential drug-drug interactions during medication ordering. Which of the following will be most important to ensure effective implementation?
Correct Answer: C
Rationale: Effective CDS balances usability. Allowing overrides with reasons , per the test and CDS best practices, maintains workflow while ensuring accountability, avoiding frustration from hard stops. Limiting to trainees misses broad use. All statuses slow systems. Constant training burdens users. This fits real-time needs, making it the correct choice.
Question 3 of 5
The nurse is assessing the perineal wound in a client who has returned from the operating room following an abdominal perineal resection and notes serosanguineous drainage from the wound. Which nursing intervention is most appropriate?
Correct Answer: C
Rationale: Serosanguineous drainage is normal post-op. Changing the dressing as prescribed aligns with wound care standards (e.g., ATI Nursing), managing expected drainage (pink, watery fluid) without escalation. Notifying the surgeon is premature unless excessive. Clamping risks fluid buildup, potentially causing infection. Removing packing disrupts healing unless ordered. Perineal resection wounds typically drain initially; routine dressing changes maintain cleanliness and monitor progress, making this the most appropriate intervention per evidence-based practice.
Question 4 of 5
The evening nurse reviews the nursing documentation in a client's chart and notes that the day nurse has documented that the client has a stage II pressure ulcer in the sacral area. Which finding would the nurse expect to note on assessment of the client's sacral area?
Correct Answer: D
Rationale: Stage II ulcers are partial. Partial-thickness loss , per NPUAP staging, shows blisters or shallow craters, matching documentation. Intact skin is stage 1. Full-thickness or exposed tissue are stages III-IV. The nurse expects dermis-level damage, guiding dressing choice, making this the correct finding.
Question 5 of 5
A client has a wound on the lower leg that is covered with dry, yellow crusts. The nurse recognizes this as an indication of:
Correct Answer: A
Rationale: Slough is the correct answer, as it refers to dead tissue that appears as dry, yellow crusts on a wound's surface, indicating tissue that needs removal to promote healing. Slough can vary in color (white, yellow, green, or brown) and texture (soft, moist, or dry), and its presence suggests the wound is not fully progressing toward recovery without intervention like debridement. Eschar is also dead tissue but is typically black, brown, or tan, with a hard, leathery texture, often serving as a natural barrier in some cases but potentially impeding healing in others. Granulation tissue is healthy, new tissue that appears red or pink, shiny, and moist, signaling active healing, not crusting. Epithelial tissue is the thin, smooth layer forming over granulation tissue in the final healing stages, not matching the dry, yellow description. The dry, yellow crusts clearly point to slough, distinguishing it from the other options based on appearance and role in wound progression.