ATI LPN
Skin Integrity and Wound Care NCLEX Questions Questions
Question 1 of 5
Which score will the nurse document for a patient with slight sensory impairment, rarely moist skin, occasional walking, slightly limited mobility, excellent meal intake, and no friction/shear issues using the Braden Scale?
Correct Answer: C
Rationale: Braden Scale scores (6-23) assess risk; lower means higher risk. Per the text: slight sensory impairment (3), rarely moist (4), walks occasionally (3), slightly limited mobility (3), excellent intake (4), no friction/shear (4) total 20 (Choice C). This reflects moderate risk, making it the correct score.
Question 2 of 5
Which intervention should be included when the nurse is cleansing a wound site?
Correct Answer: C
Rationale: Wound cleansing prevents contamination spread. Cleansing from the least contaminated area (Choice C), per the text, directs solution outward from the wound to surrounding skin, maintaining sterility. Flowing from most to least contaminated risks infection. Vigorous scrubbing damages tissue, even with noncytotoxic solutions like saline. Clean gauze/gloves are standard but not the key intervention. This method protects healing tissue, aligning with infection control principles, making it the correct inclusion.
Question 3 of 5
The nurse identifies which type of wounds heal by tertiary intention?
Correct Answer: D
Rationale: Tertiary intention involves delayed closure after being left open, unlike primary (immediate closure) or secondary (healing from the bottom up) intention.
Question 4 of 5
The nurse recognizes which intervention is not a form of mechanical debridement?
Correct Answer: D
Rationale: Enzymatic debridement uses topical agents, not mechanical means like wet-to-dry or whirlpools.
Question 5 of 5
The nurse understands which rationale to be appropriate for drying a wound after irrigation?
Correct Answer: C
Rationale: Drying prevents moisture-related skin breakdown, not infection or dressing adhesion.