ATI LPN
NCLEX Questions Skin Integrity and Wound Care Questions
Question 1 of 5
Which priority element will the nurse consider when planning care to decrease the development of a decubitus ulcer for an unconscious patient?
Correct Answer: B
Rationale: Pressure is the primary cause of decubitus ulcers, as it disrupts capillary flow when exceeding 15-32 mm Hg, leading to ischemia, per the text. For an unconscious patient, sustained pressure from immobility is the critical factor nurses address through repositioning and support surfaces. Resistance isn't a defined element here. Weight contributes indirectly via pressure distribution but isn't the root cause. Stress affects overall health, not ulcer formation directly. Pressure's intensity, duration, and tissue tolerance are measurable and actionable, making it the priority element in care planning to prevent skin breakdown in vulnerable patients.
Question 2 of 5
Which finding will alert the nurse to a potential wound dehiscence in a postoperative patient?
Correct Answer: C
Rationale: Dehiscence separation of wound layers often presents with a patient sensing 'something has given way' (Choice C), per the text, especially after strain like coughing. Organ protrusion is evisceration, a later stage. Chronic drainage or purulent drainage may signal infection, not dehiscence directly. This patient report prompts urgent nurse assessment, making it the correct alert for potential dehiscence.
Question 3 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 4 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 5 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.