ATI- Tissue Integrity

ATI TISSUE INTEGRITY 2023 QUESTIONS AND ANSWERS WITH A COMPLETE SOLUTION 1. A nurse is observing assistive personnel (AP) care for a client. Which of the following actions by AP places the client at risk for alterations in skin integrity? A. The AP places the client in high-Fowler's position. B. The AP places pillows under the client's lower extremities. C. The AP feeds the client 80% of each meal. D. The AP cleans and dries the client's perineum after each episode of incontinence.: A. The AP places the client in high-Fowler's position. Placing the client in the high-Fowler's position increases the risk for shearing and alterations in skin integrity. Shearing occurs when clients are sitting or lying on an incline, such as sitting in the high-Fowler's position in bed. As the client sits, gravity pulls deeper tissues like fat and muscle downward while the top layers of the skin are still in contact with the surface. Shearing results in stretching and trauma to the blood and lymphatic vessels. B. The AP places pillows under the client's lower extremities. -INCORRECT. Friction injuries occur when the skin rubs against an opposing force, such as heels on bed linens. Placing pillows under the client's lower extremities will elevate their heels off the bed to prevent rubbing against the bed linens. This action will decrease the client's risk for alteration in skin integrity. C. The AP feeds the client 80% of each meal. -INCORRECT. Clients who are malnourished are at a greater risk for alterations in tissue integrity. Feeding the client 80% of each meal decreases the risk for malnutrition, which decreases the risk for alteration in tissue integrity. D. The AP cleans and dries the client's perineum after each episode of inconti- nence. -INCORRECT. Skin that is exposed to irritants such as feces, urine, stoma effluent, and wound exudates is at a greater risk for alterations in integrity. Cleaning and drying the perineum after each episode of incontinence decreases the client's risk for alterations in tissue integrity.