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Tissue Integrity ATI Exam Newest 2025/2026 Actual Exam
Complete 100 Questions And Correct Detailed Answers
(Verified Answers) |Already Graded A+
A nurse is observing an assistive personnel care for a client. Which of
the following actions by the AP places the client at risk for alterations in
skin integrity? - ANSWER-The AP places the client in high-Fowler's
position.
A nurse is caring for a 6-month-old infant who has diarrhea. The nurse
should monitor the infant for which of the following alterations in tissue
integrity? - ANSWER-Dermatitis
A nurse is caring for a client who has a deep foot wound with minimal
exudate and necrotized tissue. For which of the following dressing types
should the nurse anticipate a prescription to cover the wound? -
ANSWER-Hydrogel
Hydrogel can be successfully use for debridement of wounds with
necrotized tissue and eschars, and causes minimal trauma to the healing
wound bed. They can provide moisture to or draw moisture away from
the wound dependent upon the needs of the wound.
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? - ANSWER-Clean the wound with 0.9% sodium chloride.
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To collect a wound culture use a sterile cotton applicator, the nurse
should first clean the wound with 0.9% sodium chloride to rinse away
any resident bacteria that may be present.
A nurse is caring for a client who has a portable wound bulb suction
device and notes that the drainage bulb is three-fourths full. Which of
the following actions should the nurse take? - ANSWER-Empty and
measure the drainage
The bulb of the portable wound bulb suction device should be emptied at
least every 8 hours or when it is more than half full.
A nurse is monitoring a client following a cholecystectomy. Which of
the following findings should the nurse identify as a potential
manifestation of sepsis? - ANSWER-Increased blood glucose
The nurse should identify that increased blood glucose, or
hyperglycemia, is a potential manifestation of sepsis.
A nurse is performing an admission skin assessment on a client and note
that the client has a stage 3 pressure injury to the coccyx. How should
the nurse document the appearance of this pressure injury? - ANSWER-
"Stage 3 pressure injury to the coccyx observed with full-thickness skin
loss and visible adipose tissue."
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A stage 3 pressure injury is characterized by full-thickness skin loss and
visible adipose tissue. The fascia, muscles, tendons, bone, ligament, and
cartilage are not visible in this stage.
A nurse is teaching a newly licensed nurse about wound healing by
secondary intention. Which of the following statements by the newly
licensed nurse indicates an understanding of healing by secondary
intention? - ANSWER-"This type of healing begins in the wound bed
with the generation of granulation tissue."
Secondary healing, or second intention, is a wound healing process that
takes place when the wound is left open to heal and granulation tissue
forms from the bottom up in the wound bed. The healing process is
prolonged, and the wound bed needs to be kept moist for proper healing
to occur. The risk of infection in these wounds is much higher as the
wound bed is in direct contact with the environment.
A nurse is caring for a client who has sustained a gunshot wound to the
abdomen and is 6 hours post-op. 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.
The nurse should place a sterile, saline-soaked dressing over the client's
wound to prevent the dressing from adhering to the tissue and protect the
organs until the client is taken back to surgery.
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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 dressing will need a secondary dressing for reinforcement."
An alginate dressing is not self-adhesive and needs a secondary dressing
for reinforcement.
A nurse is reviewing strategies to reduce the risk of wound dehiscence
with a client following abdominal surgery. Which of the following
responses by the client indicates an understanding of the information? -
ANSWER-"I should report any pain at my wound site."
The client should report pain at the incision site to the nurse. This can be
an indication of infection, which can lead to the client's incision to
dehisce.
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? -
ANSWER-A client who has a Braden score of 9
The lowest overall score a client can receive on the Braden Scale is a 6,
which 23 being the max score. The lower the overall score the client
receives, the greater the risk the client has for alterations in skin and
Tissue Integrity ATI Exam Newest 2025/2026 Actual Exam
Complete 100 Questions And Correct Detailed Answers
(Verified Answers) |Already Graded A+
A nurse is observing an assistive personnel care for a client. Which of
the following actions by the AP places the client at risk for alterations in
skin integrity? - ANSWER-The AP places the client in high-Fowler's
position.
A nurse is caring for a 6-month-old infant who has diarrhea. The nurse
should monitor the infant for which of the following alterations in tissue
integrity? - ANSWER-Dermatitis
A nurse is caring for a client who has a deep foot wound with minimal
exudate and necrotized tissue. For which of the following dressing types
should the nurse anticipate a prescription to cover the wound? -
ANSWER-Hydrogel
Hydrogel can be successfully use for debridement of wounds with
necrotized tissue and eschars, and causes minimal trauma to the healing
wound bed. They can provide moisture to or draw moisture away from
the wound dependent upon the needs of the wound.
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? - ANSWER-Clean the wound with 0.9% sodium chloride.
,2|Page
To collect a wound culture use a sterile cotton applicator, the nurse
should first clean the wound with 0.9% sodium chloride to rinse away
any resident bacteria that may be present.
A nurse is caring for a client who has a portable wound bulb suction
device and notes that the drainage bulb is three-fourths full. Which of
the following actions should the nurse take? - ANSWER-Empty and
measure the drainage
The bulb of the portable wound bulb suction device should be emptied at
least every 8 hours or when it is more than half full.
A nurse is monitoring a client following a cholecystectomy. Which of
the following findings should the nurse identify as a potential
manifestation of sepsis? - ANSWER-Increased blood glucose
The nurse should identify that increased blood glucose, or
hyperglycemia, is a potential manifestation of sepsis.
A nurse is performing an admission skin assessment on a client and note
that the client has a stage 3 pressure injury to the coccyx. How should
the nurse document the appearance of this pressure injury? - ANSWER-
"Stage 3 pressure injury to the coccyx observed with full-thickness skin
loss and visible adipose tissue."
,3|Page
A stage 3 pressure injury is characterized by full-thickness skin loss and
visible adipose tissue. The fascia, muscles, tendons, bone, ligament, and
cartilage are not visible in this stage.
A nurse is teaching a newly licensed nurse about wound healing by
secondary intention. Which of the following statements by the newly
licensed nurse indicates an understanding of healing by secondary
intention? - ANSWER-"This type of healing begins in the wound bed
with the generation of granulation tissue."
Secondary healing, or second intention, is a wound healing process that
takes place when the wound is left open to heal and granulation tissue
forms from the bottom up in the wound bed. The healing process is
prolonged, and the wound bed needs to be kept moist for proper healing
to occur. The risk of infection in these wounds is much higher as the
wound bed is in direct contact with the environment.
A nurse is caring for a client who has sustained a gunshot wound to the
abdomen and is 6 hours post-op. 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.
The nurse should place a sterile, saline-soaked dressing over the client's
wound to prevent the dressing from adhering to the tissue and protect the
organs until the client is taken back to surgery.
, 4|Page
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 dressing will need a secondary dressing for reinforcement."
An alginate dressing is not self-adhesive and needs a secondary dressing
for reinforcement.
A nurse is reviewing strategies to reduce the risk of wound dehiscence
with a client following abdominal surgery. Which of the following
responses by the client indicates an understanding of the information? -
ANSWER-"I should report any pain at my wound site."
The client should report pain at the incision site to the nurse. This can be
an indication of infection, which can lead to the client's incision to
dehisce.
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? -
ANSWER-A client who has a Braden score of 9
The lowest overall score a client can receive on the Braden Scale is a 6,
which 23 being the max score. The lower the overall score the client
receives, the greater the risk the client has for alterations in skin and
