ATI LPN
Skin Integrity and Wound Care NCLEX Questions Questions
Question 1 of 5
Which type of tissue will the nurse expect to observe when a wound is healing by full-thickness repair?
Correct Answer: C
Rationale: Full-thickness repair, as in Stage IV ulcers, progresses with granulation tissue red, moist, vascular tissue signaling healing, per the text. Eschar is necrotic, blocking healing. Slough is dead tissue needing removal. Purulent drainage indicates infection, not progress. Granulation marks the proliferative phase, a positive sign nurses monitor, guiding dressing choices like hydrogels, making this the correct tissue expected in healing.
Question 2 of 5
Which action should the nurse take first when changing a dressing on a wound with a drain?
Correct Answer: A
Rationale: Dressing changes cause pain. Providing analgesics 30 minutes prior (Choice A), per the text, eases discomfort, enhancing patient cooperation. Avoiding drain removal and gloves follow. Gathering supplies is preparatory. Pain management sets the stage for a smooth procedure, making this the correct first action.
Question 3 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 4 of 5
Which is the best goal for an unconscious, bedridden patient with a Stage II pressure ulcer and a nursing diagnosis of Risk for infection?
Correct Answer: D
Rationale: Goals must be measurable.'Remain free of odorous or purulent drainage' (Choice D), per the text, indicates no infection in an unconscious patient. Stating signs isn't feasible. Family actions (Choices B, C) are interventions, not goals. This outcome reflects infection prevention, making it the correct goal.
Question 5 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.