ATI: Tissue Integrity
A nurse is planning care for a client
who has urinary incontinence. The nurse
should plan to monitor the client for b. Dermatitis
which of the following findings?
A client who has urinary incontinence is
a. Fluid volume overload at risk for incontinence-associated der-
b. Dermatitis matitis and impaired tissue integrity.
c. Kidney stones
d. Hypoglycemia
A nurse is caring for a group of clients.
Which of the following clients should the
nurse identify is at highest risk for devel-
oping a pressure injury?
d. A client who is unresponsive to verbal
commands and changes position occa-
a. A client who is receiving enteral feed-
sionally.
ing and can change position indepen-
dently.
This client is at greatest risk for a pres-
b. A client who alert and responsive and
sure injury because they have a very
eats 25% of each meal.
limited sensory perception. The nurse
c. A client who makes frequent slight
should monitor the client for a pressure
changes in position and walks occasion-
injury.
ally.
d. A client who is unresponsive to verbal
commands and changes position occa-
sionally.
A nurse is caring for a client who has
a Penrose drain. Which of the following
actions should the nurse take?
c. Place a perforated gauze pad around
a. Connect the drain to continuous the drain.
low-pressure suction.
b. Clean the skin near the drain in a circu- The nurse should place a perforated
lar motion from the outside to the inside. gauze pad around the drain to collect
c. Place a perforated gauze pad around fluids from the drain.
the drain.
d. Empty the drainage device when it is
half full.
1/9
, ATI: Tissue Integrity
A nurse is teaching a class about the
function of cells in the epidermis. The
nurse should include that which of the c. Merkel cells
following are receptor cells that detect
light touch? Merkel cells are receptor cells that detect
light touch. They are primarily located in
a. Langerhans cells the palms of the hands and soles of the
b. Melanocytes feet.
c. Merkel cells
d. Keratinocytes
b. Diabetes mellitus
c. Medication history
e. Prealbumin level
The nurse is reviewing the client's med- Diabetes mellitus causes a decrease in
ical record. Which of the following find- tissue perfusion and impaired sensa-
ings places the client at risk for delayed tion, which increases the risk for de-
wound healing? layed wound healing. Corticosteroids de-
Select all that apply. crease the formation of collagen and fi-
broblasts which are needed for wound
a. Hyperlipidemia healing. The client's prealbumin level
b. Diabetes mellitus is below the expected reference range
c. Medication history which indicates malnutrition. Malnutrition
d. Cholesterol level places the client at risk for impaired
e. Prealbumin level wound healing and tissue integrity due to
a decrease in essential nutrients. Nutri-
ents, such as protein, vitamins A and C,
and fatty acids are necessary for wound
healing.
A nurse is planning care for a client who
has a superficial wound with no exu-
c. Film dressing
date. The nurse should plan to use which
of the following dressings to cover the
Film dressings or self-adhesive transpar-
wound?
ent dressings are used to cover superfi-
cial wounds that have minimal exudate.
a. Hydrofiber dressing
b. Alginate dressing
2/9
A nurse is planning care for a client
who has urinary incontinence. The nurse
should plan to monitor the client for b. Dermatitis
which of the following findings?
A client who has urinary incontinence is
a. Fluid volume overload at risk for incontinence-associated der-
b. Dermatitis matitis and impaired tissue integrity.
c. Kidney stones
d. Hypoglycemia
A nurse is caring for a group of clients.
Which of the following clients should the
nurse identify is at highest risk for devel-
oping a pressure injury?
d. A client who is unresponsive to verbal
commands and changes position occa-
a. A client who is receiving enteral feed-
sionally.
ing and can change position indepen-
dently.
This client is at greatest risk for a pres-
b. A client who alert and responsive and
sure injury because they have a very
eats 25% of each meal.
limited sensory perception. The nurse
c. A client who makes frequent slight
should monitor the client for a pressure
changes in position and walks occasion-
injury.
ally.
d. A client who is unresponsive to verbal
commands and changes position occa-
sionally.
A nurse is caring for a client who has
a Penrose drain. Which of the following
actions should the nurse take?
c. Place a perforated gauze pad around
a. Connect the drain to continuous the drain.
low-pressure suction.
b. Clean the skin near the drain in a circu- The nurse should place a perforated
lar motion from the outside to the inside. gauze pad around the drain to collect
c. Place a perforated gauze pad around fluids from the drain.
the drain.
d. Empty the drainage device when it is
half full.
1/9
, ATI: Tissue Integrity
A nurse is teaching a class about the
function of cells in the epidermis. The
nurse should include that which of the c. Merkel cells
following are receptor cells that detect
light touch? Merkel cells are receptor cells that detect
light touch. They are primarily located in
a. Langerhans cells the palms of the hands and soles of the
b. Melanocytes feet.
c. Merkel cells
d. Keratinocytes
b. Diabetes mellitus
c. Medication history
e. Prealbumin level
The nurse is reviewing the client's med- Diabetes mellitus causes a decrease in
ical record. Which of the following find- tissue perfusion and impaired sensa-
ings places the client at risk for delayed tion, which increases the risk for de-
wound healing? layed wound healing. Corticosteroids de-
Select all that apply. crease the formation of collagen and fi-
broblasts which are needed for wound
a. Hyperlipidemia healing. The client's prealbumin level
b. Diabetes mellitus is below the expected reference range
c. Medication history which indicates malnutrition. Malnutrition
d. Cholesterol level places the client at risk for impaired
e. Prealbumin level wound healing and tissue integrity due to
a decrease in essential nutrients. Nutri-
ents, such as protein, vitamins A and C,
and fatty acids are necessary for wound
healing.
A nurse is planning care for a client who
has a superficial wound with no exu-
c. Film dressing
date. The nurse should plan to use which
of the following dressings to cover the
Film dressings or self-adhesive transpar-
wound?
ent dressings are used to cover superfi-
cial wounds that have minimal exudate.
a. Hydrofiber dressing
b. Alginate dressing
2/9
