ATI LPN
NCLEX Practice Questions Skin Integrity and Wound Care Questions
Question 1 of 5
Which risk factor will the nurse assess for that predisposes a patient to pressure ulcer development?
Correct Answer: A
Rationale: Pressure ulcers result from prolonged pressure impairing blood flow to tissues. A decreased level of consciousness is a key risk factor, per *Fundamentals of Nursing*, because confused or unconscious patients can't reposition themselves to relieve pressure or communicate discomfort. This aligns with the Braden Scale's sensory perception category, where impaired awareness heightens vulnerability. Adequate dietary intake supports healing, not risk. Shortness of breath affects oxygenation but isn't a direct pressure ulcer cause. Muscular pain may limit mobility but isn't primary. Decreased consciousness directly correlates with immobility and unawareness, making it the correct answer nurses assess first in med-surg settings.
Question 2 of 5
Which nursing observation of the incision will indicate the patient is experiencing a complication of wound healing after a total abdominal hysterectomy?
Correct Answer: D
Rationale: A bluish mass suggests a hematoma a complication from blood pooling under tissues, per the text, risking pressure on vessels. Pain and itching are normal post-op. Approximation indicates proper healing. Hematomas require nurse intervention (e.g., notification), making this the correct sign of a healing complication.
Question 3 of 5
Which statement by the patient with a Stage IV pressure ulcer indicates issues with self-concept?
Correct Answer: C
Rationale: Self-concept ties to body image. Requesting a bath and linen change due to an 'awful' state reflects distress over odor and drainage, per the text, hinting at shame. Weakness is physical. Going home and dinner are positive. This statement signals emotional impact, making it the correct indicator for nurses to address.
Question 4 of 5
Which health care provider's order will the nurse question for a clean, granulating Stage III pressure ulcer?
Correct Answer: B
Rationale: Dakin's solution is cytotoxic, harming granulation tissue, per the text, and should be questioned for a clean Stage III ulcer. Low-air-loss and hydrogel support healing. Dietitian consults aid nutrition. Noncytotoxic saline is preferred, making this the correct order to challenge.
Question 5 of 5
Which action will the nurse take first to decrease the formation of pressure ulcers for an immobile patient?
Correct Answer: C
Rationale: Prevention starts with risk assessment. Determining risk factors (Choice C), per the text, identifies vulnerabilities (e.g., immobility) for tailored interventions. Fluids and nutrition support health but aren't first. Turning is key but follows risk identification. This step ensures effective planning, making it the correct first action.