ATI RN
NCLEX Questions on 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 a patient who sustained a head injury and is unconscious?
Correct Answer: B
Rationale: Pressure' is the priority to reduce decubitus ulcers in an unconscious patient. Pressure intensity e.g., >32 mmHg duration e.g., 2 hours and tissue tolerance cause ischemia e.g., sacral redness unlike 'resistance' , vague e.g., not a factor. 'Weight' contributes e.g., bony pressure but isn't primary. 'Stress' is emotional e.g., not mechanical. A nurse plans e.g., Turn q2h' cutting 60% of risk, per studies, a physiological focus. The text emphasizes pressure's role over secondary elements, making the correct, critical element.
Question 2 of 5
A patient presents to the emergency department with a laceration of the right forearm caused by a fall. After determining that the patient is stable, what is the next best step for the nurse to take?
Correct Answer: B
Rationale: After stability, 'inspect the wound for bleeding' is next. Lacerations bleed e.g., 50 mL needing control e.g., pressure unlike 'foreign bodies' , later e.g., post-hemostasis. 'Size' follows e.g., for sutures. 'Tetanus' is last e.g., history-based. A nurse checks e.g., Active bleed' per 90% of trauma protocol, a physiological must. The text prioritizes bleeding, making the correct, urgent step.
Question 3 of 5
The nurse is caring for a patient with a Stage IV pressure ulcer. Which nursing diagnosis does the nurse add to the care plan?
Correct Answer: C
Rationale: Impaired skin integrity' fits a Stage IV ulcer. Deep damage e.g., bone exposed defines this e.g., 20% incidence unlike 'enhanced nutrition' , positive e.g., not current. 'Mobility' is risk e.g., not diagnosis. 'Chronic pain' may coexist e.g., not primary. A nurse adds e.g., Impaired integrity' per NANDA, a physiological focus. The text links Stage IV to skin loss, making the correct, specific diagnosis.
Question 4 of 5
The nurse is caring for a patient who is immobile and is at risk for skin impairment. The plan of care includes turning the patient. Which is the best method for repositioning the patient?
Correct Answer: B
Rationale: Utilize a transfer device to lift the patient' is best. Lifting e.g., slide sheet cuts shear e.g., 30% less friction unlike '30-degree supine' , mispositioned e.g., not lateral. 'Elevate 45 degrees' risks ulcers e.g., >30° shear. 'Slide' drags e.g., 40% injury. A nurse uses e.g., Lift to 30° lateral' per 80% protocol, a physiological must. The text favors lifting, making the correct, safe method.
Question 5 of 5
Which fibrous protein is responsible for the strength and water resistance of the skin surface?
Correct Answer: D
Rationale: Keratin' ensures skin strength and water resistance, per ProProfs. In the epidermis e.g., stratum corneum it hardens via keratinization e.g., 15-day cycle forming a barrier e.g., 95% waterproof unlike 'keratohyalin' , a precursor e.g., granulosum role. 'Eleidin' is intermediate e.g., lucidum, not key. 'Collagen' supports dermis e.g., deeper, not surface. A histologist sees e.g., Tough outer shell' per its protective role, a physiological must. The quiz highlights keratin's surface dominance, making the correct, fibrous protein.