Skin Integrity & Wound Care - NCLEX
Style Exam 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. - 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 - 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 - 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. - 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. -
Answer-✅These are important areas to assess. Potential ulcer sites for side-lying
clients include:
1. Ankles
2. Knees
3. Trochanters
4. Ilia
5. Shoulders
6. Ears
/.The client at greatest risk for postoperative wound infection is:
1. A 3-month-old infant postoperative from pyloric stenosis repair
2. A 78-year-old postoperative from inguinal hernia repair
3. An 18-year-old drug user postoperative from removal of a bullet in the leg
4. A 32-year-old diabetic postoperative from an appendectomy - Answer-✅3. An 18-
year-old drug user postoperative from removal of a bullet in the leg; All are at risk for
infection. Answer 3 is at greatest risk, because the bullet is unclean, and a drug user is
at great risk for immune deficiency.
Style Exam 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. - 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 - 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 - 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. - 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. -
Answer-✅These are important areas to assess. Potential ulcer sites for side-lying
clients include:
1. Ankles
2. Knees
3. Trochanters
4. Ilia
5. Shoulders
6. Ears
/.The client at greatest risk for postoperative wound infection is:
1. A 3-month-old infant postoperative from pyloric stenosis repair
2. A 78-year-old postoperative from inguinal hernia repair
3. An 18-year-old drug user postoperative from removal of a bullet in the leg
4. A 32-year-old diabetic postoperative from an appendectomy - Answer-✅3. An 18-
year-old drug user postoperative from removal of a bullet in the leg; All are at risk for
infection. Answer 3 is at greatest risk, because the bullet is unclean, and a drug user is
at great risk for immune deficiency.
