ATI LPN
Skin Integrity NCLEX Questions Questions
Question 1 of 5
Which specialty bed will the nurse use for a patient with a Stage IV pressure ulcer with grafted surgical sites?
Correct Answer: B
Rationale: Air-fluidized beds redistribute pressure via fluid-like immersion, per the text, ideal for Stage IV ulcers with grafts, protecting new tissue. Low-air-loss prevents moisture buildup. Lateral rotation aids pulmonary issues. Standard mattresses lack support. This bed enhances healing, making it the correct choice.
Question 2 of 5
How long should the nurse schedule a patient at risk for skin impairment to sit in a chair?
Correct Answer: B
Rationale: Prolonged sitting increases pressure on ischial tuberosities, risking skin breakdown. Scheduling less than 2 hours (Choice B), per the text, limits ischemia, especially for at-risk patients, balancing mobility with safety. Over 3 hours exceeds safe pressure duration, per studies showing tissue damage after 2 hours. Thirty minutes is overly restrictive, reducing mobility benefits. Comfort-based duration ignores objective risk, as patients may not feel early damage. The 2-hour limit, often with cushions, is a standard nursing intervention to redistribute pressure, making this the correct choice for protecting skin integrity.
Question 3 of 5
Which action should the nurse take to assist with pain management for a postoperative medial meniscus repair of the right knee?
Correct Answer: D
Rationale: Ice (Choice D), per the text, reduces edema, bleeding, and pain post-knee surgery by numbing the area and constricting vessels. Vital signs monitor status but don't relieve pain. Checking pulses assesses circulation, not pain. A dependent leg increases swelling, worsening pain. Ice is a direct, evidence-based intervention nurses use alongside analgesics, making this the correct action for pain management.
Question 4 of 5
The nurse is caring for a postoperative patient who has had abdominal surgery and whose wound has completely eviscerated when the nurse walks into the room. In addition to notifying the surgeon, what should the nurse do?
Correct Answer: D
Rationale: Moist saline gauze prevents drying and further damage in evisceration until surgical intervention.
Question 5 of 5
The nurse knows that a hydrocolloid dressing is appropriate for use on which type of wound?
Correct Answer: D
Rationale: Hydrocolloids absorb moderate drainage and form a gel, unsuitable for heavy drainage or tunneling.