ATI LPN
Skin Integrity and Wound Care NCLEX Questions Questions
Question 1 of 5
Which of the following outcome measures is reported on the CMS Hospital Compare website?
Correct Answer: C
Rationale: CMS Hospital Compare reports standardized outcomes. 30-day MI mortality , per the test, is tracked per CMS, reflecting post-discharge care impact, publicly available since 2007. Rapid response activations and survival post-arrest are internal metrics, not CMS-reported. Follow-up within 2 weeks isn't a standard CMS outcome. This measure drives hospital accountability, linking to payment via value-based programs, making it the correct choice per CMS policy.
Question 2 of 5
A nurse is admitting a client to the unit. Which cultural question is most appropriate?
Correct Answer: A
Rationale: Culturally respectful care seeks client input. Asking about dietary needs and preferences aligns with transcultural nursing (e.g., Leininger's model), capturing specifics like kosher or halal diets, fostering trust. Choice B assumes standard food fits, ignoring culture. Choice C is narrow, missing preferences. Choice D is incomplete and unclear due to OCR error, likely irrelevant. Per nursing standards, open-ended questions ensure individualized care, respecting beliefs (e.g., fasting practices), making this the most appropriate question.
Question 3 of 5
The nurse is monitoring a wound in a dark-skinned client for signs of erythema. How would the nurse best determine the presence of erythema?
Correct Answer: D
Rationale: Erythema in dark skin isn't always red. Palpating for increased temperature , per wound assessment texts (e.g., Potter & Perry), detects inflammation reliably, as color changes may appear ashen or purple. Drainage indicates infection, not erythema. Swelling is secondary. Dark skin requires tactile cues over visual, ensuring accurate monitoring for complications like infection, making this the best method.
Question 4 of 5
A client is recovering and the nurse would encourage the client to eat which food item that is naturally high in vitamin C to promote wound healing?
Correct Answer: B
Rationale: Vitamin C aids collagen. Oranges , per nutrition science, are high in vitamin C (~70mg/fruit), boosting wound repair. Milk offers protein, not C. Bananas provide potassium. Chicken supports protein, not C. Encouraging citrus enhances healing, per dietary guidelines, making this the correct food.
Question 5 of 5
A nurse is applying a dressing to a wound that has moderate to heavy exudate. Which of the following types of dressing would be most appropriate for this wound?
Correct Answer: D
Rationale: Alginate is the correct answer because it is highly absorbent, capable of managing moderate to heavy exudate by absorbing up to 20 times its weight in fluid, making it ideal for such wounds. It forms a gel when in contact with exudate, maintaining a moist environment that supports healing and autolytic debridement, while preventing maceration of surrounding skin. Transparent film is non-absorbent and suited for dry wounds, offering protection but not fluid management. Hydrogel is minimally absorbent and better for dry or minimally exudative wounds, providing hydration rather than absorption. Foam is moderately absorbent, handling light to moderate exudate, but less effective than alginate for heavy drainage due to its lower capacity (up to four times its weight). The wound's moderate to heavy exudate requires a dressing like alginate to effectively manage fluid and promote optimal healing conditions.