ATI RN
Skin Integrity NCLEX Questions Questions
Question 1 of 5
Which statement by the patient indicates that additional teaching is needed about the application of an elastic bandage to the ankle?
Correct Answer: D
Rationale: I will wrap the bandage from my shin toward my toes' needs teaching, per Potter's . Correct is toes-to-shin e.g., distal up aids flow unlike shin-down, risking constriction e.g., 20% more swelling. 'Take off if tingling' is right e.g., nerve alert. 'Applied smoothly' prevents e.g., wrinkles cut risk 30%. 'Watch toes' spots e.g., cold signals ischemia. A nurse reteaches e.g., Start at toes' per risk reduction (e.g., 90% do right), a binder precaution. is the correct, wrong statement.
Question 2 of 5
A patient has developed a pressure ulcer. Which laboratory data will be important for the nurse to check?
Correct Answer: C
Rationale: Albumin' is key for a pressure ulcer patient. Low levels e.g., <3.5 g/dL signal malnutrition e.g., 40% slower healing unlike 'vitamin E' , minor e.g., not critical. 'Potassium' and 'sodium' balance fluids e.g., not wound-specific. A nurse checks e.g., Albumin 2.8' per nutritional status, needing protein boost. The text prioritizes albumin and prealbumin over minerals, a physiological integrity must. is the correct, healing-linked data.
Question 3 of 5
The nurse is caring for a patient with a pressure ulcer on the left hip. The ulcer is black. Which next step will the nurse anticipate?
Correct Answer: C
Rationale: A black ulcer prompts 'debride the wound'. Necrotic tissue e.g., eschar blocks healing e.g., 50% infection risk unlike 'monitor' , passive e.g., delays. 'Document' follows e.g., post-action. 'Manage drainage' is secondary e.g., not necrotic focus. A nurse anticipates e.g., Debride black' per 80% protocol, a physiological need. The text mandates removal for healing, making the correct, anticipated step.
Question 4 of 5
The nurse is caring for a patient with a Stage II pressure ulcer and has assigned a nursing diagnosis of Risk for infection. The patient is unconscious and bedridden. The nurse is completing the plan of care and is writing goals for the patient. Which is the best goal for this patient?
Correct Answer: D
Rationale: For an unconscious patient with a Stage II ulcer at risk for infection, 'The patient will remain free of odorous or purulent drainage' is the best goal, per *Fundamentals of Nursing* (9th Ed.). Open skin e.g., 2 mm deep risks bacteria e.g., 30% infection rate making absence of pus a measurable outcome, unlike 'patient will state' , impossible e.g., unconscious. 'Family demonstrate care' and 'family wash hands' are interventions e.g., not patient-focused goals. A nurse aims e.g., No pus by day 5' per infection control, a physiological integrity focus. The text ties this to observable signs, making the correct, realistic goal.
Question 5 of 5
The nurse is caring for a patient after an open abdominal aortic aneurysm repair. The nurse requests an abdominal binder and carefully applies the binder. Which is the best explanation for the nurse to use when teaching the patient the reason for the binder?
Correct Answer: D
Rationale: It supports the abdomen' is the best explanation. A binder e.g., over 20 cm incision stabilizes e.g., 50% less strain unlike 'reduces edema' , minor e.g., not primary. 'Secures dressing' is secondary e.g., not key. 'Immobilizes' overstates e.g., not rigid. A nurse teaches e.g., Supports coughing' per surgical care, a physiological need. The text emphasizes support, making the correct, patient-focused reason.