ATI LPN
NCLEX Practice Questions Skin Integrity and Wound Care Questions
Question 1 of 5
You note a change in mental status in an older adult patient, with flushed, warm, dry skin, full pulse, and low urine output. The priority action is:
Correct Answer: C
Rationale: Altered mental status, warm/dry skin, and oliguria suggest sepsis. Taking vital signs first confirms severity (e.g., fever, tachycardia), per ABCs, guiding urgency. Notifying or drawing blood follows data. History delays. Vitals provide objective evidence, an LPN priority, making it the correct first action.
Question 2 of 5
Which risk factor will the nurse assess for that predisposes a patient to pressure ulcer development?
Correct Answer: A
Rationale: Pressure ulcers result from prolonged pressure impairing blood flow to tissues. A decreased level of consciousness is a key risk factor, per *Fundamentals of Nursing*, because confused or unconscious patients can't reposition themselves to relieve pressure or communicate discomfort. This aligns with the Braden Scale's sensory perception category, where impaired awareness heightens vulnerability. Adequate dietary intake supports healing, not risk. Shortness of breath affects oxygenation but isn't a direct pressure ulcer cause. Muscular pain may limit mobility but isn't primary. Decreased consciousness directly correlates with immobility and unawareness, making it the correct answer nurses assess first in med-surg settings.
Question 3 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 4 of 5
Which nursing observation of the incision will indicate the patient is experiencing a complication of wound healing after a total abdominal hysterectomy?
Correct Answer: D
Rationale: A bluish mass suggests a hematoma a complication from blood pooling under tissues, per the text, risking pressure on vessels. Pain and itching are normal post-op. Approximation indicates proper healing. Hematomas require nurse intervention (e.g., notification), making this the correct sign of a healing complication.
Question 5 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.