NCLEX Questions Integumentary System

Extract:

Question 1 of 5

The wound care nurse documented a client’s pressure ulcers on admission as 3.3 cm × 4 cm stage II on the coccyx. Which information would alert the nurse that the client’s pressure ulcer is getting worse?

A. The skin is not broken and is 2.5 cm × 3.5 cm with erythema that does not blanch. B. There is a 3.2-cm × 4.1-cm blister that is red and drains occasionally. C. The skin covering the coccyx is intact but the client complains of pain in the area. D. The coccyx wound extends to the subcutaneous layer and there is drainage.

Correct Answer: D

Rationale: Extension to the subcutaneous layer with drainage indicates progression to stage III or IV, worsening the ulcer. Smaller size, blisters, or pain are less severe.

Question 2 of 5

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Question 3 of 5

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Question 4 of 5

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Question 5 of 5

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NCLEX Questions Integumentary System | Nurselytic

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