Question A nurse is assessing a patient with limited mobility and notices a reddened area over the sacral region. The patient complains of discomfort in that area. What action should the nurse prioritize?
A. Apply a cold compress to the reddened area
B. Massage the area gently to increase circulation
C. Reposition the patient to relieve pressure on the area
D. Apply a heating pad to alleviate discomfort
E. Document the finding and continue routine care
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Rationale: The priority in managing pressure ulcers is to relieve pressure on the affected area. Repositioning helps redistribute pressure, preventing further tissue damage. Applying cold or heat and massaging the area can potentially exacerbate the injury. Documenting the finding is important, but immediate intervention to address the cause of pressure is crucial in preventing further skin breakdown. Correct Answer: C. Reposition the patient to relieve pressure on the area
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Question A nurse is providing education to a group of elderly patients at a nursing home about preventing skin breakdown. What action by the nurse is most appropriate?
A. Encourage increased intake of sugary beverages
B. Advocate for regular turning and repositioning every 2 hours
C. Recommend using harsh soaps for bathing
D. Suggest sitting in one position for extended periods
E. Advise applying adhesive bandages to potential pressure areas
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Rationale: Regular turning and repositioning alleviate pressure on bony prominences, reducing the risk of pressure ulcers. Encouraging sugary beverages can be detrimental to skin health due to their potential inflammatory effects. Harsh soaps can dry and damage the skin. Prolonged sitting in one position and using adhesive bandages can increase pressure and cause skin damage. Correct Answer: B. Advocate for regular turning and repositioning every 2 hours
POP QUIZ
@qbankproacademy 4000+ Free NCLEX QUESTIONS. Go to QBankProAcademy.com FREE Qbank questions for NCLEX RN, PN, HESI Exit, Med Surg, AANP, ANCC, and HesiA2. Practice questions, quizzes, and listen to the Free Podcast. In this video, we review a question on SKIN INTEGRITY, PRESSURE ULCERS, and WOUND CARE in Nursing. At QbankproAcademy.com our mission is to provide free QBanks, videos, and the most up to date test prep information for nurses. If you find our website helpful, please tell other aspiring nurses, nursing students, and professors. Please link to our site from your blogs, videos, and college websites, or share us on your favorite social media sites. Thank you for your support! nclex Nurses Nursing aanp qbank ancc hesi medsurg qbank
1000 HESI Exit Questions
Understanding Skin Integrity: Causes and Symptoms
Question A patient with diabetes presents with a foot ulcer. The nurse is assessing the wound. What finding suggests the need for immediate medical attention?
A. Absence of drainage from the wound
B. Redness and warmth around the wound site
C. Foul odor emanating from the wound
D. Presence of granulation tissue in the wound bed
E. Minimal pain reported by the patient
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Rationale: A foul odor from a wound suggests possible infection, which requires immediate medical attention. Absence of drainage might indicate poor circulation. Redness, warmth, and granulation tissue are signs of healing. Minimal pain in diabetic patients might be due to neuropathy, but foul odor indicates a potential infection requiring urgent attention to prevent further complications. Correct Answer: C. Foul odor emanating from the wound
1000 Medical-Surgical Questions
Question A nurse is caring for a patient who has been immobile due to a recent surgery. The nurse notices a reddened area on the patient’s lower back. Upon touch, the area feels warmer than the surrounding skin. What action should the nurse take first?
A. Apply a heating pad to the reddened area
B. Massage the area gently to increase circulation
C. Reposition the patient to relieve pressure on the area
D. Cleanse the area with a strong antiseptic solution
E. Apply a protective barrier cream over the area
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Rationale: The priority in managing pressure ulcers is to relieve pressure on the affected area. Repositioning helps redistribute pressure, preventing further tissue damage. Applying heat, massaging the area, or using strong antiseptics can exacerbate the injury or damage the skin further. Protective barrier creams are preventive but do not address the immediate need for relieving pressure. Correct Answer: C. Reposition the patient to relieve pressure on the area
Question A nurse is caring for a bedridden patient and notices an open wound with yellowish drainage on the patient’s left hip. The surrounding skin appears red and inflamed. What stage of pressure ulcer is this likely indicating?
A. Stage I
B. Stage II
C. Stage III
D. Stage IV
E. Unstageable
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Rationale: Stage III pressure ulcers involve full-thickness skin loss, extending into the subcutaneous tissue and presenting with visible adipose tissue. The presence of yellowish drainage, redness, and inflammation indicates tissue damage beyond the superficial layers, classifying it as a Stage III ulcer. Stages I and II involve less tissue depth, while Stage IV involves deep tissue damage. Unstageable ulcers have obscured depths due to tissue covering the wound. Correct Answer: C. Stage III
Understanding Skin Integrity Care: NCLEX Delegation Questions
Question A nurse is performing a skin assessment on an elderly patient with limited mobility. The patient has darkly pigmented skin. Which assessment technique is best for identifying early signs of skin breakdown in this patient?
A. Visual inspection with a bright light source
B. Palpation for skin temperature changes
C. Regularly asking the patient about skin discomfort
D. Using a skin marker to outline potential problem areas
E. Evaluating skin turgor by pinching the skin
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Rationale: Darkly pigmented skin can make early signs of skin breakdown less apparent. Visual inspection with a bright light source helps identify subtle changes in skin color, allowing for early detection of discoloration or erythema. Palpation might detect changes in texture or moisture but might miss early color changes. Asking about discomfort is important but might not reveal subtle skin changes. Using a marker or evaluating skin turgor might not effectively detect early signs in darker skin tones. Correct Answer: A. Visual inspection with a bright light source
Understanding Skin Integrity: NCLEX Priority Questions
Question A nurse is caring for a patient with limited mobility who has developed a pressure ulcer on the left heel. The wound appears shallow with a reddened base and intact skin surrounding it. What stage of pressure ulcer does this presentation indicate?
A. Stage I
B. Stage II
C. Stage III
D. Stage IV
E. Unstageable
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Rationale: Stage II pressure ulcers involve partial-thickness skin loss, with the wound extending through the epidermis and dermis. The shallow ulcer with a reddened base and intact surrounding skin aligns with Stage II characteristics. Stage I ulcers involve intact skin with non-blanchable erythema, while Stage III involves full-thickness skin loss and Stage IV extends deeper, involving muscle or bone. Unstageable ulcers have obscured depths due to tissue covering the wound. Correct Answer: B. Stage II
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NCLEX Questions: Focus on Medications for Skin Integrity
Question A nurse is providing care to an elderly patient who is at risk for skin breakdown due to immobility. Which intervention best prevents pressure ulcers in this population?
A. Encouraging prolonged sitting to increase tolerance
B. Applying lotion to dry skin areas twice daily
C. Using a donut-shaped cushion for seating
D. Turning and repositioning the patient regularly
E. Applying heat packs to potential pressure areas
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Rationale: Regular turning and repositioning redistribute pressure, reducing the risk of pressure ulcers in immobile patients. Encouraging prolonged sitting increases pressure, worsening the risk. While moisturizing dry skin is beneficial, it alone doesn’t prevent ulcers. Donut-shaped cushions can increase pressure on specific areas. Heat packs can exacerbate tissue damage by increasing local blood flow. Correct Answer: D. Turning and repositioning the patient regularly
NCLEX Questions Critical Thinking: Skin Integrity Symptoms
Question A nurse is assessing a patient’s wound healing process. The wound shows pinkish-red granulation tissue with minimal serosanguinous drainage. What phase of wound healing is the patient likely in? A. Inflammatory phase
B. Proliferative phase
C. Maturation phase
D. Hemostasis phase
E. Epithelialization phase
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Rationale: The proliferative phase involves granulation tissue formation and angiogenesis, leading to the appearance of pinkish-red tissue. Minimal serosanguinous drainage is typical in this phase as the wound undergoes tissue repair. The inflammatory phase is characterized by hemostasis and inflammation. The maturation phase involves remodeling and scar formation, while epithelialization involves surface tissue closure. Correct Answer: B. Proliferative phase
NCLEX Review: Skin Integrity Treatments
Question A nurse is caring for a patient with a wound that appears black and adherent to the wound bed. The nurse suspects the presence of necrotic tissue. What type of wound is most likely presenting these characteristics?
A. Pressure ulcer
B. Arterial ulcer
C. Venous ulcer
D. Diabetic foot ulcer
E. Surgical wound infection
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Rationale: Black, adherent tissue often indicates the presence of necrotic tissue, commonly seen in pressure ulcers due to compromised blood flow and tissue damage. Arterial ulcers typically have pale, yellow, or black necrosis. Venous ulcers may have yellow slough, while diabetic foot ulcers can present with various characteristics. Surgical wound infections show signs of inflammation and purulent discharge but may not always present as black and adherent tissue. Correct Answer: A. Pressure ulcer
