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Skin/Pressure Ulcer NCLEX Practice Questions from Lippincott, and Saunders Questions And Answers 2022

Multiple Choice Identify the choice that best completes the statement or answers the question.

• The evening nurse reviews the nursing documentation in a client’s chart and notes that the day nurse has

documented that the client has a stage II pressure ulcer in the sacral area. Which finding would the nurse expect to note on assessment of the client’s sacral area?

• Intact Skin c. Exposed bone, tendon, or muscle
• Full-thickness skin loss d. Partial-thickness skin loss of the dermis
• Which of the following is an appropriate nursing intervention for a client at risk for developing a pressure

ulcer?

• Massaging over the reddened area to

improve circulation

• Positioning the HOB at a 45 degree angle

to improve tissue perfusion

• Using hot, soapy water for pericare

• Repositioning a bedfast client at least

every two hours

• Which of the following diagnostic tests is most relevant for assessing the risk of developing a pressure

ulcer for a 73 year old client with no health issues?

• White blood cells c. Red blood cells
• Serum albumin d. Serum potassium
• Which of the following clients would least likely be at risk for developing skin breakdown?
• An incontinent client c. A client with decreased sensory perception
• A client with nutritional deficiencies d. A client who is unable to move about and

is confined to bed

• The nurse is reviewing the health care record of a male clients scheduled to be seen at the health care

clinic. The nurse determines that which of the following individuals is at greatest risk for development of an integumentary disorder?

• An adolescent c. A physical education teacher
• An older female d. An outdoor construction worker
• The nurse is teaching a female client with a leg ulcer about tissue repair and wound healing. Which of the

following statements by the client indicates effective teaching?

• “I’ll limit my intake of protein” c. “My foot should feel cold”
• “I’ll make sure that the bandage is

wrapped tightly”

• “I’ll eat plenty of fruits and vegetables”
• A nurse is reviewing the nursing care plan for a client for whom a stage 4 pressure ulcer has been

documented. Which of the following would the nurse expect to note on the client assessment?

• A reddened area that returns to normal

skin color after 15 to 20 minutes of pressure relief

• An area in which the top layer of skin is

missing

• Intact skin d. A deep ulcer that extends into muscle and

bone

• A nurse notes documentation of stage 3 pressure ulcer in a client’s record. Which of the following would

the nurse expect to note on client assessment?

• A deep ulcer that extends into muscle and

bone

• An area in which the top layer of skin is

missing

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• A deep ulcer that extends into the dermis

and the subcutaneous tissue

• A reddened area that returns to normal

skin color after 15 to 20 minutes of pressure relief

• The nurse is assessing a client with dark skin for the presence of a stage 1 pressure ulcer. The nurse

should:

• Use a fluorescent light source to assess the

skin.

• Inspect the skin only when the Braden

score is above 12.

• Look for skin color that is darker than the

surrounding tissue.

• Avoid touching the skin during inspection.
• The nurse is assessing a hospitalized older client for the presence of pressure ulcers. The nurse notes that

the client has a 1” x 1” area on the sacrum in which there is skin breakdown as far as the dermis. What should the nurse note on the chart?

• Stage I pressure ulcer c. Stage III pressure ulcer
• Stage II pressure ulcer d. Stage IV pressure ulcer
• The nurse is assessing a client who is immobile and notes an area of sacral skin is reddened, but not

broken. The reddened area continues to blanch and refill with fingertip pressure. The most appropriate

nursing action at this time is to:

• Apply a moist to moist dressing, being

careful to pack just the wound bed

• Consult with a wound-ostomy-continence

nurse specialist.

12. A stage II pressure ulcer is characterized by:

• Reposition the client off of the reddened

skin and reassess in a few hours.

• Complete and document a Braden skin

breakdown risk score for the client.

• Redness in the involved area c. Pain in the involved area
• Muscle spasms in the involved area d. Tissue necrosis in the involved area
• The nurse is using home telehealth monitoring to manage care for an 80-year-old who is home bound.

The client spends most of the day in bed. Two months ago, the nurse detected sacral redness from friction and shearing force of being in bed. Last month, the client had increase sacral redness and the area was classified as a Stage I pressure ulcer. On this visit, the nurse is assessing the sacral area using a video camera. The nurse compares the site from a visit made 1 month ago to the assessment made at this visit and the wound is now open and red in appearance. Upon comparing the change of the pressure ulcer from this visit to the previous visit, the nurse should do which of the following first?

• Instruct the home health aide to reposition

the client every 2 hours while the client is awake.

• Ask the client’s daughter to purchase a

foam mattress.

• Contact the physician to request a

hydrocolloid dressing.

• Suggest that the client ask a neighbor to

purchase antibiotic cream at the drugstore.

• The nurse finds an unlicensed assistive personnel (UAP) massaging the reddened bony prominences of a

client on bed rest. The nurse should:

• Reinforce the UAP’s use of this

intervention over the bony prominences.

• Explain that massage is effective because

it improves blood flow to the area.

• Inform the UAP that massage is even

more effective when combined with lotion during the massage.

• Instruct the UAP that the massage is

contraindicated because it decreases blood flow to the area.

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• The nurse manager on the orthopedic unit is reviewing a report that indicates that in the last month five

clients were diagnosed with pressure ulcers. The nurse manager should:

(This type question will not be on your test, you haven’t had leadership yet. I included to see how you would do)

• Use benchmarking procedures to compare

the findings with other nursing units in the hospital.

• Ask the staff education department to

conduct an educational session about preventing pressure ulcers.

• Institute a quality improvement plan that

identifies contributing factors, proposes solutions, and sets improvement outcomes.

• Conduct a chart audit to determine which

nurses on which shifts were giving care to the clients with pressure ulcers.

• The nurse is evaluating the client’s risk for having a pressure sore. Which of the following is the best

indicator of risk for the client developing a pressure sore?

• Nutritional status c. Mobility status
• Circulatory status d. Orientation status

Multiple Response Identify one or more choices that best complete the statement or answer the question.

• A client has been admitted to the hospital with draining foot lesions. The nurse should do which of the

following? Select all that apply.

• Place the client in a room with negative air d. Post a “contact isolation” sign on the door.

pressure.

• Admit the client to a semi-private room. e. Wear a protective gown when in the

client’s room.

• Admit the client to a private room. f. Wear latex-free gloves when providing

direct care.

• A client has a wound on the ankle that is not healing. The nurse should assess the client for which of the

following risk factors for delayed wound healing?

• Atrial fibrillation d. Hypertension
• Advancing age e. Smoking
• Type 2 diabetes mellitus