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: Priority follows acuity. Appendicitis with a heating pad , per the flashcards, risks rupture an emergency outweighing a chronic Stage IV ulcer . A Braden score of 18 is low risk. An approximated incision is normal. Heat exacerbates inflammation, per nursing principles, demanding immediate nurse action to prevent peritonitis, making this the correct first patient.
Question 2 of 5
The nurse is caring for a patient on the medical-surgical unit with a wound that has a drain and a dressing that needs changing. Which action should the nurse take first?
Correct Answer: A
Rationale: Dressing changes hurt. Providing analgesics first , per the flashcards, eases pain 30 minutes prior, aiding cooperation. Avoiding drain removal , gloves , and supplies follow. Pain management sets the stage, making this the correct first action.
Question 3 of 5
The nurse is completing a skin risk assessment using the Braden Scale. The patient has slight sensory impairment, has skin that is rarely moist, walks occasionally, and has slightly limited mobility, along with excellent intake of meals and no apparent problem with friction and shear. Which score will the nurse document for this patient?
Correct Answer: C
Rationale: Braden scores (6-23) assess risk; higher is better. Per the flashcards: slight sensory (3), rarely moist (4), walks occasionally (3), slight mobility (3), excellent intake (4), no friction/shear (4) = 20 . This is moderate risk, making it the correct score.
Question 4 of 5
The nurse is caring for a patient with a Stage II pressure ulcer and has assigned a nursing diagnosis of Risk for infection. The patient is unconscious and bedridden. Which is the best goal for this patient?
Correct Answer: D
Rationale: Measurable goals suit unconscious patients. Remain free of odorous or purulent drainage' , per the flashcards, indicates no infection. Stating signs isn't possible. Family actions (Choices B, C) are interventions. This reflects prevention, making it the correct goal.
Question 5 of 5
The nurse leaves a pressure ulcer open to air and does not apply a dressing. Which stage pressure ulcer does this patient have?
Correct Answer: A
Rationale: Stage I ulcers intact, red heal without dressings , per the flashcards, resolving in 7-14 days with relief. Stage II , III , and IV need dressings for deeper damage. Open-to-air suits Stage I, making this the correct stage.