ATI LPN
Skin Integrity NCLEX Questions Questions
Question 1 of 5
You are caring for a patient with an epidural infusion. Which sign requires immediate provider notification?
Correct Answer: A
Rationale: Epidural analgesia risks hypotension from vasodilation. BP 80/60 signals shock, needing urgent notification, per anesthesia protocols. Temp 99.5°F is mild. Respirations 12/min are normal. Low urine is concerning but slower. Hypotension threatens perfusion, an LPN alert, making it the correct sign.
Question 2 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 3 of 5
What is the next best step for the nurse upon noticing an odor and purulent discharge with increased redness at a healing Stage III pressure ulcer site?
Correct Answer: A
Rationale: Odor, purulent discharge, and redness suggest infection. Completing a full assessment vitals, treatment, labs gathers data for accurate reporting, per the text, before notifying providers. SBAR notification follows assessment. Consulting wound care or the charge nurse is secondary. Comprehensive data collection ensures informed care escalation, making this the correct next step.
Question 4 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 5 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.