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Integumentary NCLEX practice questions

Five NCLEX-style questions on burns, pressure injuries, wound care and skin infections. Pick your answer, then open it to see the right choice and why. New questions every week.

1. Question 1

   A nurse is preparing to irrigate a wound for a patient. What actions should the nurse plan to take?

   • A.Chill the irrigant prior to the procedure.
   • B.Irrigate the wound until the solution that is draining is clean.
   • C.Hold the tip of the syringe at least 13 cm (0.5 in) above the wound while irrigating.
   • D.Flush the wound from the most contaminated area to the cleanest area.
   Show answer and rationale ▾Answer and rationale ▴

   Answer: B. Irrigate the wound until the solution that is draining is clean.

   Chilling the irrigant prior to the procedure is not recommended. Cold irrigant can cause discomfort and potentially lead to vasoconstriction, which can impede the healing process. Irrigating the wound until the solution that is draining is clean is a standard practice in wound care. This helps to ensure that all debris and potential contaminants are removed from the wound. Holding the tip of the syringe at least 13 cm (0.5 in) above the wound while irrigating is not a standard practice. The syringe should be held close to the wound to ensure effective irrigation. Flushing the wound from the most contaminated area to the cleanest area is not a standard practice. The wound should be irrigated from the cleanest to the dirtiest area to prevent the spread of contamination.

2. Question 2

   A nurse is assessing a patient’s wound dressing and observes a watery red drainage. How should the nurse document this type of drainage?

   • A.Purulent.
   • B.Sanguineous.
   • C.Serosanguineous.
   • D.Serous.
   Show answer and rationale ▾Answer and rationale ▴

   Answer: C. Serosanguineous.

   Purulent drainage is thick and opaque. It can have a yellow, tan, green, or brown color and is a sign of infection. Sanguineous drainage is bright red and indicates active bleeding3. Serosanguineous drainage is typically pink-red and thin. It is made up of blood and serous fluid and is typically seen in a normal, non-infected wound3. Serous drainage is clear and thin, like the fluid from a blister3.

3. Question 3

   A nurse is assessing a patient who has a wound that is healing by first intention. What findings should the nurse expect?

   • A.Granulation tissue forming at the bottom of the wound bed.
   • B.Wound was contaminated at the time of injury.
   • C.Healing of the wound is prolonged.
   • D.Skin edges of the wound are sutured closed.
   Show answer and rationale ▾Answer and rationale ▴

   Answer: D. Skin edges of the wound are sutured closed.

   Granulation tissue forming at the bottom of the wound bed is a characteristic of secondary intention healing, not primary intention. In secondary intention, the wound is left open and fills with granulation tissue. A wound that was contaminated at the time of injury would likely require secondary intention healing to allow for cleaning and observation of the wound. This is not typical of primary intention healing. Prolonged healing of the wound is not a characteristic of primary intention healing. In primary intention, the wound edges are brought together (approximated), which allows for rapid healing. In primary intention healing, the skin edges of the wound are sutured closed. This is the most distinctive feature of primary intention healing, as it allows for minimal scar formation and quick healing.

4. Question 4

   The nurse notes that a patient has a black pressure ulcer on the left hip. Which event will the nurse anticipate when planning care for this patient?

   • A.Surgical debridement of the wound
   • B.Increased drainage from the wound
   • C.Documenting the wound status daily
   • D.Increased monitoring of the wound condition
   Show answer and rationale ▾Answer and rationale ▴

   Answer: A. Surgical debridement of the wound

   A black pressure ulcer indicates necrotic tissue, which often requires surgical debridement. Increased drainage from the wound is not typically associated with a black pressure ulcer. While documenting the wound status daily is part of wound care, it is not a specific event anticipated when planning care for a patient with a black pressure ulcer. Increased monitoring of the wound condition is part of wound care, but it is not a specific event anticipated when planning care for a patient with a black pressure ulcer.

5. Question 5

   A nurse is changing a wound dressing for a post-op client. Which of the following steps is the nurse performing?

   • A.Planning.
   • B.Evaluation.
   • C.Assessment.
   • D.Implementation.
   Show answer and rationale ▾Answer and rationale ▴

   Answer: D. Implementation.

   Planning involves setting goals and determining the appropriate interventions to achieve those goals. It is not the step being performed when changing a wound dressing. Evaluation involves assessing the effectiveness of the interventions and determining if the goals have been met. It is not the step being performed when changing a wound dressing. Assessment involves gathering data about the client’s condition. While assessment is an ongoing process, it is not the primary step being performed when changing a wound dressing. Implementation involves carrying out the planned interventions. Changing a wound dressing is an example of implementing a nursing intervention.