ATI LPN
NCLEX Questions Skin Integrity and Wound Care Questions
Question 1 of 5
Which patient will the nurse see first?
Correct Answer: C
Rationale: Prioritization follows ABCs and acuity. A patient with appendicitis using a heating pad is urgent heat risks rupture, per the text, threatening peritonitis. A Stage IV ulcer is serious but stable. A Braden score of 18 indicates low risk (cutoff 18). An approximated incision is normal healing. The appendicitis patient's immediate danger trumps chronic or stable conditions, making this the correct first priority for nurse intervention.
Question 2 of 5
What is the next best step for the nurse after determining a patient with a forearm laceration is stable?
Correct Answer: B
Rationale: Post-stabilization, bleeding is the priority, per trauma protocols, as lacerations may hemorrhage profusely, requiring control. Foreign bodies and size follow. Tetanus is later. Inspecting bleeding ensures hemodynamic stability, making this the correct next step for nurses.
Question 3 of 5
Which assessment is the priority when completing a skin integrity assessment?
Correct Answer: A
Rationale: Pressure points (Choice A), like bony prominences, are the priority, per the text, as they're prone to ulcers. Breath (Choice B), bowel (Choice C), and pulse sounds inform overall status but aren't skin-specific. Visual/tactile checks at pressure sites detect early damage, making this the correct focus.
Question 4 of 5
Which health care team member will the nurse consult for a patient with impaired skin integrity?
Correct Answer: B
Rationale: Nutrition aids healing. A registered dietitian (Choice B), per the text, optimizes calories and protein for skin integrity, critical for pressure ulcers. Respiratory therapists address breathing. Case managers plan discharge. Chaplains offer spiritual support. Dietitian collaboration enhances recovery, making this the correct consult.
Question 5 of 5
Which action should the nurse take for a patient who appears anxious as the nurse prepares to change a wound dressing?
Correct Answer: B
Rationale: Anxiety during dressing changes stems from uncertainty. Explaining the procedure (Choice B), per the text, educates and involves the patient, reducing fear by giving control and predictability. Television distracts but doesn't address anxiety's root. Closing eyes avoids engagement, potentially increasing tension. Asking family to leave may isolate the patient, worsening distress if they're a support. Explanation aligns with therapeutic communication, calming the patient and aiding cooperation, making this the correct action for nurses to take.