Skin Integrity & Wound Care - NCLEX
Style Questions and answers
A client has a pressure ulcer with a shallow, partial skin thickness, eroded area but no necrotic areas. The
nurse would treat the area with which dressing?
1. Alginate
2. Dry Gauze
3. Hydrocolloid
4. No dressing indicated. -Correct Answer-3. Hydrocolloid; Hydrocolloid dressings protect shallow ulcers
and maintain an appropriate healing environment.
Alginates (option 1) are used for wounds with significant drainage; dry gauze (option 2) will stick to
granulation tissue, causing more damage. A dressing is needed to protect the wound and enhance
healing.
Which of the following are primary risk factors for pressure ulcers? Select all that apply.
1. Low-protein diet
2. Insomnia
3. Lengthy surgical procedures
4. Fever
5. Sleeping on a waterbed -Correct Answer-1, 3, & 4; Risk factors for pressure ulcers include a low-
protein diet, lengthy surgical procedures, and fever.
Protein is needed for adequate skin health and healing. During surgery, the client is on a hard surface
and may not be well protected from pressure on bony prominences. Fever increases skin moisture,
which can lead to skin breakdown, plus the stress on the body from the cause of the fever could impair
circulation and skin integrity. Insomnia (option 2) would generally involve restless sleeping, which
transfers pressure to different parts of the body and would reduce chances of skin breakdown. A
waterbed (option 5) distributes pressure more evenly than a regular mattress and, thus, actually reduces
the chance of skin breakdown.
, An appropriate nursing diagnosis for a client with large areas of skin excoriation resulting from scratching
an allergic rash is:
1. Risk for Impaired Skin Integrity
2. Impaired Skin Integrity
3. Impaired Tissue Integrity
4. Risk for Infection -Correct Answer-2. Impaired Skin Integrity; The client has an actual impairment of
the skin due to the rash and the scratching so is no longer "at risk".
Because the damage is at the skin level, it is not impaired tissue integrity (option 3) since that would
involve deeper tissues. Surface excoriation is also not prone to becoming infected.
Which statement, if made by the client or family member, would indicate the need for further teaching?
1. If a skin area gets red but then the red goes away after turning, I should report it to the nurse.
2. Putting foam pads under the heels or other bony areas can help decrease pressure.
3. If a person cannot turn himself in bed, someone should help them change position q4h.
4. The skin should be washed with only warm water (not hot) and lotion put on while it is still a little wet.
-Correct Answer-3. If a person cannot turn himself in bed, someone should help them change position
q4h; Immobile and dependent persons should be repositioned at least every 2 hours, not every 4, so this
client or family member requires additional teaching.
Warm water and moisturizing damp skin are correct techniques for skin care. Red areas that do not
return to normal skin color should be reported. It would also be correct to use a foam pad to help relieve
pressure.
The client is only comfortable lying on the right side or left side (not on the back or stomach). List at least
four potential sites of pressure ulcers the nurse must assess. -Correct Answer-These are important areas
to assess. Potential ulcer sites for side-lying clients include:
1. Ankles
2. Knees
Style Questions and answers
A client has a pressure ulcer with a shallow, partial skin thickness, eroded area but no necrotic areas. The
nurse would treat the area with which dressing?
1. Alginate
2. Dry Gauze
3. Hydrocolloid
4. No dressing indicated. -Correct Answer-3. Hydrocolloid; Hydrocolloid dressings protect shallow ulcers
and maintain an appropriate healing environment.
Alginates (option 1) are used for wounds with significant drainage; dry gauze (option 2) will stick to
granulation tissue, causing more damage. A dressing is needed to protect the wound and enhance
healing.
Which of the following are primary risk factors for pressure ulcers? Select all that apply.
1. Low-protein diet
2. Insomnia
3. Lengthy surgical procedures
4. Fever
5. Sleeping on a waterbed -Correct Answer-1, 3, & 4; Risk factors for pressure ulcers include a low-
protein diet, lengthy surgical procedures, and fever.
Protein is needed for adequate skin health and healing. During surgery, the client is on a hard surface
and may not be well protected from pressure on bony prominences. Fever increases skin moisture,
which can lead to skin breakdown, plus the stress on the body from the cause of the fever could impair
circulation and skin integrity. Insomnia (option 2) would generally involve restless sleeping, which
transfers pressure to different parts of the body and would reduce chances of skin breakdown. A
waterbed (option 5) distributes pressure more evenly than a regular mattress and, thus, actually reduces
the chance of skin breakdown.
, An appropriate nursing diagnosis for a client with large areas of skin excoriation resulting from scratching
an allergic rash is:
1. Risk for Impaired Skin Integrity
2. Impaired Skin Integrity
3. Impaired Tissue Integrity
4. Risk for Infection -Correct Answer-2. Impaired Skin Integrity; The client has an actual impairment of
the skin due to the rash and the scratching so is no longer "at risk".
Because the damage is at the skin level, it is not impaired tissue integrity (option 3) since that would
involve deeper tissues. Surface excoriation is also not prone to becoming infected.
Which statement, if made by the client or family member, would indicate the need for further teaching?
1. If a skin area gets red but then the red goes away after turning, I should report it to the nurse.
2. Putting foam pads under the heels or other bony areas can help decrease pressure.
3. If a person cannot turn himself in bed, someone should help them change position q4h.
4. The skin should be washed with only warm water (not hot) and lotion put on while it is still a little wet.
-Correct Answer-3. If a person cannot turn himself in bed, someone should help them change position
q4h; Immobile and dependent persons should be repositioned at least every 2 hours, not every 4, so this
client or family member requires additional teaching.
Warm water and moisturizing damp skin are correct techniques for skin care. Red areas that do not
return to normal skin color should be reported. It would also be correct to use a foam pad to help relieve
pressure.
The client is only comfortable lying on the right side or left side (not on the back or stomach). List at least
four potential sites of pressure ulcers the nurse must assess. -Correct Answer-These are important areas
to assess. Potential ulcer sites for side-lying clients include:
1. Ankles
2. Knees
