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ATI RN · ATI Fundamentals · NCLEX Practice Questions Skin Integrity and Wound Care

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Showing all 5 practice questions with expert explanatory rationales.

Question 1 of 5

The nurse is completing an assessment on a patient with a Stage IV pressure ulcer. The wound is odorous, and a drain is currently in place. Which statement by the patient indicates issues with self-concept?

A. I am so weak and tired. I want to feel better

B. I am thinking I will be ready to go home early next week

C. I am ready for my bath and linen change right now since this is awful

D. I am hoping there will be something good for dinner tonight

Expert Explanatory Rationale

Correct Answer: I am ready for my bath and linen change right now since this is awful

Question 2 of 5

During the assessment of these high-risk areas, the nurse finds no redness, but the underlying tissue feels spongy. What action should the nurse implement?

A. Apply heat to reduce the inflammation that has occurred at these sites?

B. Notify the healthcare provider that the client is retaining excessive fluid

C. Reassure the client that no pressure damage is present at these sites.

D. Identify these areas as sites where pressure damage has occurred.

Expert Explanatory Rationale

Correct Answer: Identify these areas as sites where pressure damage has occurred.

Question 3 of 5

A nurse is assessing a patient with a stage IV pressure ulcer. What assessment of the ulcer would be expected?

A. full-thickness skin loss

B. skin pallor

C. blister formation

D. eschar formation

Expert Explanatory Rationale

Correct Answer: full-thickness skin loss

Question 4 of 5

Which glands' secretions are metabolized by bacteria to produce most body odor?

A. Apocrine sweat

B. Ceruminous

C. Merocrine sweat

D. Sebaceous

Expert Explanatory Rationale

Correct Answer: Apocrine sweat

Question 5 of 5

Which of the following actions involves the greatest risk of skin shearing?

A. Inserting a peripheral intravenous catheter

B. Rolling the client from a supine to side-lying position

C. Pulling the client up in bed

D. Helping the client ambulate after surgery

Expert Explanatory Rationale

Correct Answer: Pulling the client up in bed

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