SKIN INTEGRITY & WOUND CARE -
NCLEX STYLE EXAM 2025 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. - ANS 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 - ANS 1, 3, & 4; Risk factors for pressure ulcers include a low-
protein diet, lengthy surgical procedures, and fever.
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, 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 - ANS 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. - ANS 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.
Copyright ©2025 THEBRIGHT ALL RIGHTS RESERVED 2
NCLEX STYLE EXAM 2025 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. - ANS 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 - ANS 1, 3, & 4; Risk factors for pressure ulcers include a low-
protein diet, lengthy surgical procedures, and fever.
Copyright ©2025 THEBRIGHT ALL RIGHTS RESERVED 1
, 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 - ANS 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. - ANS 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.
Copyright ©2025 THEBRIGHT ALL RIGHTS RESERVED 2
