ATI LPN Fundamentals Proctored Exam(Wound)

Which characteristic distinguishes a stage 2 pressure injury from a stage 3 pressure injury?

A patient with diabetes presents with a non-healing foot ulcer. Which factor is most likely contributing to wound ischemia in this patient?

A nurse observes drainage that is pale pink and watery. How should this be documented?

A patient with a contaminated abdominal wound from a motor vehicle accident is being considered for tertiary intention healing. What is the primary reason for choosing this method?

A nurse is caring for a patient who is 8 days post-abdominal surgery and reports sudden discomfort at the incision site. Upon examination, the nurse notices the wound edges are partially separated wit

A nurse is assessing a patient with a suspected deep tissue pressure injury on their heel. The skin is intact but shows a deep maroon discoloration. What immediate action should the nurse take?

A nurse is caring for a bedridden client who shows early signs of skin breakdown on the sacrum. Which intervention should the nurse prioritize to address this issue?

A patient with a confirmed MRSA skin infection is being treated with vancomycin. What nursing action is most critical to ensure the effectiveness of the treatment?

A nurse is providing care for a patient with excessive diaphoresis. Which intervention is most appropriate to prevent skin breakdown?

A nurse notices bright red sanguineous drainage on a surgical dressing shortly after surgery. What is the most appropriate initial action?

What is the most appropriate nursing intervention for a wound draining bright red sanguineous fluid?

During an assessment, a nurse notes purulent drainage from a patient's open wound. What does this finding suggest?

A nurse is caring for a patient with limited mobility and notices a stage I pressure injury on the sacrum. What would be the most appropriate nursing intervention?

A patient with an abrasion covered by a bandage reports increased drainage and irritation at the site. What should the nurse do first?

A nurse is assessing a patient with paraplegia using the Braden Scale. The patient reports occasional moist skin and poor appetite, and frequently slides down in their wheelchair. What is the most lik

What is the primary reason for using a lift device when repositioning a patient with impaired mobility?

A nurse is teaching a patient about prevention of stage 1 pressure ulcers. Which statement by the patient indicates a need for further teaching?

Which dietary intervention is most important for promoting skin integrity in clients at risk for breakdown?

Upon assessment, a nurse suspects that a patient with a recent abdominal surgery is at risk of evisceration. Which of the following factors most strongly contributes to this risk?