ATI LPN
NCLEX Questions Skin Integrity and Wound Care Questions
Question 1 of 5
You are observing a nursing student perform a dressing change. You would intervene if the student:
Correct Answer: D
Rationale: Dressing changes balance sterility and practicality. Using sterile gloves to remove old dressing is incorrect clean gloves suffice, per infection control, reserving sterile for new application. Gathering supplies (Choice A), identifying patient (Choice B), and hand hygiene with clean gloves are standard. Sterile removal wastes resources and risks contamination later, needing intervention, making it the correct action.
Question 2 of 5
A patient with chronic pain asks, 'What is a TENS unit?' The best nursing response is:
Correct Answer: B
Rationale: TENS (transcutaneous electrical nerve stimulation) uses skin electrodes to disrupt pain signals, per gate control theory.'Small electrical stimulus' accurately describes it, per nursing texts. Epidural is invasive, not TENS. Finger pressure is acupressure. Support misleads. Clear explanation aids use, an LPN response, making it the correct answer.
Question 3 of 5
Which priority element will the nurse consider when planning care to decrease the development of a decubitus ulcer for an unconscious patient?
Correct Answer: B
Rationale: Pressure is the primary cause of decubitus ulcers, as it disrupts capillary flow when exceeding 15-32 mm Hg, leading to ischemia, per the text. For an unconscious patient, sustained pressure from immobility is the critical factor nurses address through repositioning and support surfaces. Resistance isn't a defined element here. Weight contributes indirectly via pressure distribution but isn't the root cause. Stress affects overall health, not ulcer formation directly. Pressure's intensity, duration, and tissue tolerance are measurable and actionable, making it the priority element in care planning to prevent skin breakdown in vulnerable patients.
Question 4 of 5
Which patient will the nurse see first?
Correct Answer: C
Rationale: Prioritization follows ABCs and acuity. A patient with appendicitis using a heating pad is urgent heat risks rupture, per the text, threatening peritonitis. A Stage IV ulcer is serious but stable. A Braden score of 18 indicates low risk (cutoff 18). An approximated incision is normal healing. The appendicitis patient's immediate danger trumps chronic or stable conditions, making this the correct first priority for nurse intervention.
Question 5 of 5
Which finding will alert the nurse to a potential wound dehiscence in a postoperative patient?
Correct Answer: C
Rationale: Dehiscence separation of wound layers often presents with a patient sensing 'something has given way' (Choice C), per the text, especially after strain like coughing. Organ protrusion is evisceration, a later stage. Chronic drainage or purulent drainage may signal infection, not dehiscence directly. This patient report prompts urgent nurse assessment, making it the correct alert for potential dehiscence.