NRSNG NCLEX Practice Question and Revised Answers
A nurse assesses an 86-year-old patient who is a client at a long-term care facility. The nurse uses the Braden scale to determine the patients level of risk for skin breakdown. After completing the assessment the nurse gives the patient a score of...
NRSNG NCLEX Practice Question and
Revised Answers
A nurse assesses an 86-year-old patient who is a client at a long-term care facility. The nurse
uses the Braden scale to determine the patients level of risk for skin breakdown. After
completing the assessment the nurse gives the patient a score of 8. Which of the following best
describes this patients risk of skin breakdown?
A. High Risk
B. Mild Risk
C. Moderate
D. Very Low Risk - answers✓✓Correct Answer:
A. High Risk
Rationale:
The Braden Scale is an assessment tool used to determine the level of risk a patient has for skin
breakdown. The Braden Scale uses several measures that can contribute to skin breakdown; the
nurse then gives the patient a score based on these measures and adds the total. A low score of 8
indicates that the patient is at high risk of skin breakdown.
A patient arrives in the recovery room after surgical wound debridement with a negative-
pressure wound system in place. Which best describes how this type of therapy helps a wound to
heal?
A. The wound vacuum removes granulation tissue if it develops
B. The negative pressure decreases collagen production in the wound bed
C. The wound vacuum stimulates keratinocyte formation
D. The negative pressure draws the edges of the wound together - answers✓✓Correct Answer:
D. The negative pressure draws the edges of the wound together
An immobile client has developed an area of skin breakdown on his hip. The nurse recognizes
that there are several factors that potentially contributed to this skin breakdown. Select all of the
following extrinsic factors that would have contributed to skin breakdown in a patient.
A. Nutrition
B. Moisture
C. Friction
D. Shear
E. Tissue Perfusion - answers✓✓Correct Answer:
B. Moisture
C. Friction
D. Shear
Rationale:
Skin breakdown can occur to various factors; extrinsic factors are those in the environment that
most likely contribute to a patient's loss of skin integrity. Examples of extrinsic factors that
contribute to skin breakdown include moisture on the patient's skin and skin injury, such as
through friction or shear forces.
An elderly patient has developed a pressure ulcer from long periods of immobility. The nurse
places a transparent dressing over the top of the wound. Which best describes why a nurse would
use a transparent dressing?
A. It is stable even if it becomes wet
B. It has the ability to absorb more exudate
D. It is usually impregnated with antimicrobial solution - answers✓✓Correct Answer:
C. It allows the nurse to visualize the wound
Rationale:
There are a number of dressing types a nurse may use when caring for a patients wound; the type
to choose depends on the extent and depth of the wound, as well as the amount of exudate
present. The nurse may apply a transparent dressing over the wound to protect it and to still
visualize the wound underneath. A transparent dressing is typically not useful when there are
large amounts of exudate present.
The nurse is charting a skin assessment on the newly admitted client. The client has a puss filled
hair follicle on their neck. The nurse should chart this using what terminology?
A. Striae
B. Fissure
C. Petechia
D. Comedo - answers✓✓Correct Answer:
D. Comedo
Rationale:
Striae are pink or silver lines from the skin stretching. Fissures are linear wedge shaped cracks in
the skin. Petechia are tiny lessions of purpura that are not palpable. Comedo is a plugged hair
follicle such as a pimple.
A nurse is caring for a patient who has a pressure ulcer on his sacrum from immobility. The
nurse ensures that the patient is turned frequently while in bed. Which would most likely
demonstrate that the patient is responding to this intervention?
A. The patient does not develop infection in the wound bed
B. The patient does not complain of pain from the wound
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