Skin Integrity

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Sample questions from Skin Integrity

This material has 90 questions with answers and rationales. Here are the first 5.

1. 1.On a medical-surgical unit, a 76-year-old client with a stage 3 sacral pressure injury has a temperature of 38.4 C, HR 112/min, BP 94/58 mm Hg, and new confusion. Which action should the nurse take first?

   • A.Notify the rapid response team and initiate sepsis protocol per facility policy
   • B.Request a nutrition consult
   • C.Apply a warm compress to the wound
   • D.Document the change and reassess in 1 hour

   Rationale: Hypotension, tachycardia, fever, and acute confusion suggest sepsis with possible impaired perfusion, requiring immediate escalation. A warm compress does not address systemic deterioration, delayed reassessment is unsafe, and nutrition support is not the immediate priority. Recognize systemic infection in a client with a wound and act promptly.

2. 2.Refer to the client's chart. Which interventions should the nurse include in the plan of care for the client's sacral pressure injury? Select all that apply.

   • A.Keep the head of the bed elevated as high as possible at all times
   • B.Rub the nonblanchable area during each turn
   • C.Reposition the client on an individualized schedule and document position changes
   • D.Consult the wound care team for treatment planning
   • E.Cleanse the wound gently and use a moisture barrier for surrounding skin
   • F.Use a pressure-redistributing support surface

   Rationale: Scheduled repositioning, pressure redistribution, gentle wound care, moisture protection, and wound-care consultation address pressure, moisture, and treatment needs. Rubbing nonblanchable tissue can cause further damage, and unnecessarily high head-of-bed elevation increases shear. The chart shows immobility, incontinence, and a new nonblanchable sacral area, so prevention of further injury is essential.

3. 3.A home health nurse visits a 79-year-old client with a new stage 2 pressure injury. The client is bedbound, and the caregiver says there is time for only one intervention before leaving for work. Which action should the nurse prioritize teaching?

   • A.Limit fluids to reduce incontinence
   • B.Leave the client sitting upright in bed for comfort
   • C.Reposition the client and establish a reliable turning plan with the caregiver
   • D.Apply lotion to the intact skin once daily

   Rationale: Reducing sustained pressure through repositioning is central to preventing progression and new pressure injuries. Lotion alone does not relieve pressure, fluid restriction can cause dehydration, and prolonged upright positioning can increase pressure and shear. The plan should be individualized and feasible for the caregiver.

4. 4.Refer to the client's chart. Which actions are appropriate for the nurse to take for the client's diabetic foot ulcer? Select all that apply.

   • A.Keep pressure off the affected foot as directed
   • B.Arrange prompt evaluation of the worsening wound and possible infection
   • C.Use the prescribed antimicrobial treatment and monitor the response
   • D.Review daily foot inspection and when to seek care
   • E.Encourage the client to walk barefoot at home to improve circulation
   • F.Trim calluses with a razor to reduce pressure

   Answer and rationale are in the full material.

5. 5.A registered nurse in an outpatient wound clinic is assigning care for four clients. Which task is appropriate to delegate to an experienced unlicensed assistive personnel (UAP)?

   • A.Measure and stage a newly discovered pressure injury
   • B.Reposition a stable client at the scheduled time and report any skin changes
   • C.Teach a client how to inspect diabetic feet
   • D.Select a dressing for a draining wound

   Answer and rationale are in the full material.