TISSUE INTEGRITY ATI QUESTIONS &
CORRECT ANSWERS/ A+
GRADED|LATEST UPDATE 2025
A nurse is performing an admission skin assessment on a client and
notes that the client has a stage 3 pressure injury to the coccyx. How
should the nurse document the appearance of this pressure injury? -
CORRECT-ANSWER-Stage 3 pressure injury to the coccyx observed
with full-thickness skin loss and visible adipose tissue
Stage 1: an area of non-blanchable erythema.
Stage 2: partial thickness skin loss with a pink and moist wound bed
Stage 3: Full-thickness skin loss with visible adipose tissue.
Stage 4: Full-thickness loss with visible muscle and bone
, 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
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? -
CORRECT-ANSWER-"I should increase my protein intake."
A nurse is planning care for an older adult clients who is bedridden.
Which of the following actions should the nurse include in the plan to
prevent skin breakdown? - CORRECT-ANSWER-Tilt the client on their
side at 30 degrees
Rationale: The nurse should include in the clients plan of care to tilt
the client on their side at 20 to 30 degrees. This prevents the client
from sliding down in bed, which can cause shearing of the skin, while
also relieving pressure to the client's hip.
CORRECT ANSWERS/ A+
GRADED|LATEST UPDATE 2025
A nurse is performing an admission skin assessment on a client and
notes that the client has a stage 3 pressure injury to the coccyx. How
should the nurse document the appearance of this pressure injury? -
CORRECT-ANSWER-Stage 3 pressure injury to the coccyx observed
with full-thickness skin loss and visible adipose tissue
Stage 1: an area of non-blanchable erythema.
Stage 2: partial thickness skin loss with a pink and moist wound bed
Stage 3: Full-thickness skin loss with visible adipose tissue.
Stage 4: Full-thickness loss with visible muscle and bone
, 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
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? -
CORRECT-ANSWER-"I should increase my protein intake."
A nurse is planning care for an older adult clients who is bedridden.
Which of the following actions should the nurse include in the plan to
prevent skin breakdown? - CORRECT-ANSWER-Tilt the client on their
side at 30 degrees
Rationale: The nurse should include in the clients plan of care to tilt
the client on their side at 20 to 30 degrees. This prevents the client
from sliding down in bed, which can cause shearing of the skin, while
also relieving pressure to the client's hip.
