Skin Integrity & Wound Care - NCLEX Style Questions

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".