- | Page
TISSUE INTEGRITY ATI QUESTIONS &
CORRECT ANSWERS/ GRA DED A+
Question : A nurse is providing teaching to a client who is in a
wheelchair about measures to avoid skin breakdown. Which of the following instructions by the nurse is related to preventing skin breakdown?
Correct answer: You should shift your weight off your
buttocks at intervals throughout the day
Question : A wound, ostomy and continence nurse (WOCN)
is providing an in service to a group of nurses about documentation of pressure injuries. Which of the following statements by one of the group members indicates an understanding of the teaching?
Correct answer: Pressure injury documentation includes
location, stage, measurements and condition of the wound bed and any drainage present
Question : A nurse is caring for a client who has sustained a
gunshot wound to the abdomen and is 6 hr postoperative. The nurse notices protrusion of the client's organs from the
- | Page
incision site and call for help. Which of the following actions should the nurse take?
Correct answer: Cover the client's wound with a sterile saline
dressing
Question : A nurse is teaching assistive personnel (AP) about
the skin of older adults. Which of the following statements by the AP indicates an understanding of the teaching?
Correct answer: The skin of older adults is thinner and has
less subcutaneous padding over bony prominences
Question : A nurse is preparing to obtain a wound culture
from a client who has a suspected wound infection. Which of the following actions should the nurse take?
Correct answer: Clean the wound with 0.9% sodium chloride
Question : A nurse is assisting with the care of a client
following abdominal surgery. The nurse removes the client's surgical dressing and notes a separation of the wound edges.The nurse should identify that the client is experiencing which of the following complications?
- | Page
Correct answer: Dehiscence
Question : A nurse is providing teaching to a client about
staple removal. Which of the following statements should the nurse include in the teaching?
Correct answer: Your staples will be removed in about 2
weeks
Question : A nurse is caring for a group of clients. Which of
the following clients should the nurse identify as having the highest risk for developing alterations in tissue integrity?
Correct answer: A client who is incontinent and taking a
prescribed diuretic
Question : A nurse is caring for a client who has dime-sized
stage 1 pressures injury located on the sacrum. Which of the following dressing types should the nurse use?
Correct answer: A transparent film
- | Page
Question : A nurse is providing teaching to a newly licensed
nurse about the functions of the skin. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching
Correct answer: The skin assists in the regulation of body
temperature
Question : A nurse has completed the Braden scale on four
clients who are at risk for alterations in skin integrity. Which of the following clients should the nurse recognize as having the greatest risk for altered skin integrity?
Correct answer: A clients who has a Braden scale score of 9
Question : A nurse is teaching a client who has a pressure
injury on their leg about proper nutrition to facilitate wound healing. Which of the following client statements indicates an understanding of the teaching?