ATI LPN
Skin Integrity NCLEX Questions Questions
Question 1 of 5
Which type of wound healing will the nurse consider when planning care for a patient in the burn unit?
Correct Answer: B
Rationale: Burns, with significant tissue loss, heal by secondary intention (Choice B), per the text, where the wound fills with scar tissue over time, increasing infection risk. Partial-thickness repair is for minor skin loss. Tertiary intention delays closure. Primary intention is for surgical wounds. Secondary intention's prolonged process requires nurses to manage infection and granulation, making this the correct healing type for burn care planning.
Question 2 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 3 of 5
Which nursing diagnosis does the nurse add to the care plan for a patient with a Stage IV pressure ulcer?
Correct Answer: C
Rationale: Stage IV ulcers involve severe skin loss, warranting 'Impaired skin integrity' (Choice C), per NANDA-I, reflecting the primary issue. Enhanced nutrition is a goal, not diagnosis. Mobility and pain may coexist but aren't central. This diagnosis drives wound care, making it the correct addition.
Question 4 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 5 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.