ATI TISSUE INTEGRITY GUARANTEED PASS!!
A nurse is collecting data from a client who has a stage 3 pressure injury on the coccyx. Which of the
following alterations in tissue integrity should the nurse expect to find? - (ANSWER)Full-thickness skin
loss with visible adipose tissue
A nurse is assisting with discharge teaching for a client who has a stage 1 pressure injury to the sacrum.
Which of the following instructions should be included to the client's caregiver to prevent further skin
breakdown? - (ANSWER)Flex the client's knees while in bed.
A nurse is assisting with the care of a client who has a dime-size stage 1 pressure injury located on the
sacrum. Which of the following dressing types should the nurse use? - (ANSWER)A transparent film
A nurse is assisting with the care of 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 incision site and calls for
help. Which of the following actions should the nurse take? - (ANSWER)Cover the client's wound with a
sterile saline dressing.
A nurse is contributing to the plan of care for an older adult client who is bedridden. Which of the
following actions should the nurse include in the plan to prevent skin breakdown? - (ANSWER)Tilt the
client on their side at 30°
A nurse is reinforcing teaching with 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? -
(ANSWER)"You should shift your weight off your buttocks at intervals throughout the day."
A nurse is reinforcing teaching with 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? - (ANSWER)"I should increase my protein intake."
A nurse is providing teaching for a client who has a prescription for an alginate dressing for a wound.
Which of the following statements by the client indicates an understanding of an alginate dressing? -
(ANSWER)This type of dressing will need a secondary dressing for reinforcement."
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A nurse is collecting data from a client who has a stage 3 pressure injury on the coccyx. Which of the
following alterations in tissue integrity should the nurse expect to find? - (ANSWER)Full-thickness skin
loss with visible adipose tissue
A nurse is assisting with discharge teaching for a client who has a stage 1 pressure injury to the sacrum.
Which of the following instructions should be included to the client's caregiver to prevent further skin
breakdown? - (ANSWER)Flex the client's knees while in bed.
A nurse is assisting with the care of a client who has a dime-size stage 1 pressure injury located on the
sacrum. Which of the following dressing types should the nurse use? - (ANSWER)A transparent film
A nurse is assisting with the care of 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 incision site and calls for
help. Which of the following actions should the nurse take? - (ANSWER)Cover the client's wound with a
sterile saline dressing.
A nurse is contributing to the plan of care for an older adult client who is bedridden. Which of the
following actions should the nurse include in the plan to prevent skin breakdown? - (ANSWER)Tilt the
client on their side at 30°
A nurse is reinforcing teaching with 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? -
(ANSWER)"You should shift your weight off your buttocks at intervals throughout the day."
A nurse is reinforcing teaching with 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? - (ANSWER)"I should increase my protein intake."
A nurse is providing teaching for a client who has a prescription for an alginate dressing for a wound.
Which of the following statements by the client indicates an understanding of an alginate dressing? -
(ANSWER)This type of dressing will need a secondary dressing for reinforcement."
Page 1 of 3
