Nclexrn Quiz: Skin Integrity And Pressure Injury Prevention

What this quiz covers

This quiz focuses on Skin Integrity And Pressure Injury Prevention, giving you a quick way to practice the rules, question types, and explanations that matter most for Nclexrn.

How to use this quiz

Try each quiz question before looking at the correct answer. Use the explanations to review missed ideas, then come back to similar questions until the pattern feels familiar.

Question 1

1. Document the finding and reassess the area in 4 hours to determine whether it resolves
2. Apply a transparent film dressing over the trochanter and keep the client in the left lateral position
3. Reposition the client to offload the left trochanter and initiate a turning schedule with pressure-redistribution support (correct answer)
4. Cleanse the area with antiseptic solution and vigorously rub to stimulate circulation

Question 2

1. Place pillows to float the heels off the bed and use a pressure-redistribution mattress while minimizing shear during repositioning (correct answer)
2. Apply talcum powder to the sacrum and heels to keep skin dry throughout the shift
3. Keep the head of the bed at 45 degrees at all times to reduce aspiration risk
4. Wait to reposition until the client is hemodynamically stable and no longer requires vasopressors

Question 3

1. Apply a moisture barrier product and implement a scheduled toileting and prompt incontinence care with gentle cleansing and drying (correct answer)
2. Obtain a wound culture of the perineal area to rule out infection before starting skin care
3. Use full-strength antiseptic cleanser with vigorous scrubbing after each incontinent episode
4. Restrict oral fluids in the evening to reduce urine output and prevent moisture on the skin

Question 4

1. Capillary refill less than 2 seconds in fingers
2. Respiratory rate 20/min with oxygen saturation 94% on 2 L/min
3. Reports mild thirst
4. Nonblanchable redness over the ischial tuberosities after prolonged sitting (correct answer)

Question 5

1. Apply a pH-balanced moisturizer to dry skin after bathing to maintain the skin barrier.
2. Use hot water and antibacterial soap for daily baths to reduce infection risk. (correct answer)
3. Use a lift sheet to minimize friction and shear when repositioning the client in bed.
4. Implement a regular turning schedule and document the skin assessments on the chart.

Question 6

1. Resident requests to delay turning until after a meal
2. Scant serous drainage noted on the heel dressing
3. Pain rated 3/10 at the heel during dressing change
4. New numbness with cooler toes and a faint pedal pulse on the affected side (correct answer)

Question 7

1. Apply a moisture barrier ointment after each incontinence episode and implement a scheduled toileting and cleansing plan (correct answer)
2. Use hot water and vigorous scrubbing to remove stool from the skin
3. Place a donut cushion under the sacrum while the client is in bed
4. Wait for a wound care consult before initiating any skin protection measures

Question 8

1. Continue frequent repositioning and offload the sacrum; avoid massaging the reddened area (correct answer)
2. Massage the reddened area until it blanches to restore circulation
3. Apply an ice pack to the area for 20 minutes to reduce inflammation
4. Cover the area with a tight elastic bandage to reduce swelling

Question 9

1. Offload pressure from the area immediately and notify the wound care resource per facility protocol. (correct answer)
2. Apply a low-temperature heating pad over the discolored area for 15 minutes to increase blood flow and help the tissue recover.
3. Reassess the area in 24 hours to determine whether it will blanch and document the finding in the medical record.
4. Scrub the area with soap and water to remove suspected bruising and then apply a moisturizing barrier.

Question 10

1. Use a pressure-redistributing wheelchair cushion and limit uninterrupted sitting time
2. Apply a donut-shaped cushion to relieve pressure on the coccyx while seated (correct answer)
3. Reposition at least every 2 hours in bed and encourage weight shifts when seated
4. Assess the skin at least daily and with each incontinence episode

Question 11

1. Apply full-strength povidone-iodine to the periwound skin after each stool
2. Cover the area with dry gauze only and change it once daily
3. Avoid cleansing after stools to prevent further irritation
4. Use a fecal management plan as appropriate and apply a moisture barrier to protect periwound skin (correct answer)

Question 12

1. Remove the oxygen and nasogastric tube for 2 hours each shift to allow the skin to rest
2. Reposition and pad the tubing contact points and assess the skin under the device at least once per shift (correct answer)
3. Apply adhesive tape tightly to prevent any movement of the tubing on the skin
4. Document the redness and wait for a provider order to adjust device positioning

Question 13

1. Diaphoresis with moist skin in dependent areas (correct answer)
2. Pain rated 6/10 with movement
3. Heart rate 88/min and blood pressure 128/76 mm Hg
4. Reports sleeping poorly overnight

Question 14

1. Remove wrinkles and debris from the bed and reposition the client using a lift sheet to reduce friction and shear (correct answer)
2. Apply a small amount of scented lotion to the client's back after the bath to promote comfort and reduce dry skin
3. Obtain a detailed dietary history before addressing the wrinkled linens because nutrition supports the client's skin integrity
4. Ask the provider for an order to change the bed linens and for clarification about the repositioning schedule before moving the client

Question 15

1. Cleanse the wound with normal saline and apply a moisture-retentive dressing while protecting periwound skin with a barrier product (correct answer)
2. Leave the wound open to air after cleansing to allow the wound bed to dry and reduce the serous drainage
3. Obtain a provider order for prophylactic systemic antibiotics to prevent bacterial infection, since the resident has a draining wound and is incontinent
4. Massage the periwound area every shift with an emollient lotion to increase blood flow and prevent further breakdown of the fragile skin

Question 16

1. Teach the client to perform pressure relief in the wheelchair at least every 15–30 minutes and to limit uninterrupted sitting time (correct answer)
2. Recommend that the client cleanse reddened areas with hydrogen peroxide and apply a zinc oxide barrier to protect the skin
3. Instruct the client to apply a heating pad to the buttocks for 20 minutes in the evening to improve circulation and relieve local redness
4. Advise the client to restrict fluid intake after midday to prevent urinary incontinence and keep the skin dry, reducing moisture-related damage

Question 17

1. Arrange adaptive equipment or caregiver support to apply moisturizer and support regular repositioning and skin checks (correct answer)
2. Recommend that the client use rubbing alcohol after bathing to decrease itching, because it leaves the skin dry and clean
3. Encourage the client to stay in one comfortable position while napping to reduce joint pain and avoid repeated friction
4. Instruct the client to apply talcum powder to dry skin daily to absorb moisture and prevent skin irritation

Question 18

1. Advise the client to limit fluid intake in the evening and to consume fewer beverages during the last two hours before reclining.
2. Recommend applying talcum powder to the client's perineum after episodes of urinary incontinence and using absorbent pads while sitting in the recliner.
3. Instruct the client to use a donut-shaped cushion in the recliner to lift the sacral area off the seat and reduce pressure.
4. Teach the client to shift weight at least every 15 minutes while sitting and to change position at least every 2 hours when resting. (correct answer)

Question 19

1. Massage the reddened sacral area for 5 minutes per shift to improve circulation and promote comfort in the surrounding tissue
2. Reposition the client at least every 2 hours using a draw sheet and offload the sacrum with pillows or wedges (correct answer)
3. Document the erythema and reassess the area at the end of the shift to see whether a pressure injury has developed
4. Request a provider order before applying a moisture barrier to the perineal area to prevent moisture-associated skin damage

Question 20

1. Wait for a provider order before implementing a turning schedule, and keep the client in a supine position until that order is received.
2. Use a thin layer of cornstarch powder in the groin folds after an episode of urine leakage, and keep the area open to air during subsequent skin assessments.
3. Reduce the frequency of perineal care and avoid cleaning the skin folds too often so the skin's natural surface oil can act as a barrier.
4. Keep skin clean and dry, use moisture-wicking textiles as available, and apply a moisture barrier to areas exposed to urine. (correct answer)