ATI LPN
NCLEX Practice Questions Skin Integrity and Wound Care Questions
Question 1 of 5
Which type of healing will the nurse consider when planning care for a patient with a Stage IV pressure ulcer?
Correct Answer: B
Rationale: Stage IV pressure ulcers, with exposed bone or muscle, heal by full-thickness repair (Choice B), per the text, involving hemostasis, inflammatory, proliferative, and maturation phases due to deep tissue loss. Partial-thickness repair suits shallow wounds. Primary intention is for clean, closed incisions. Tertiary intention delays closure. Full-thickness healing addresses scar formation in severe ulcers, guiding nurses to plan debridement and grafting, making this the correct healing type for care planning.
Question 2 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 3 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 4 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.
Question 5 of 5
A nurse leaves a pressure ulcer open to air without a dressing. To which patient did the nurse provide care?
Correct Answer: A
Rationale: Stage I pressure ulcers intact skin with nonblanchable redness heal without dressings (Choice A), per the text, resolving in 7-14 days with pressure relief. Stage II requires moisture-retentive dressings like hydrocolloids for partial-thickness loss. Stage III and IV need advanced dressings (e.g., hydrogels) for deeper damage. Open-to-air is appropriate only for Stage I, as it avoids unnecessary intervention while promoting natural recovery, making this the correct patient for the nurse's care approach.