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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+/
Latest Exam!!!
A nurse is observing an assistant personnel (AP) care for
a client. Which of the following actions by the 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. - Answer-A. 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?
A. Cellulitis
B. Skin tears
C. Premature Wrinkling
D. Dermatitis - Answer-D. Dermatitis
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A nurse is providing teaching to 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?
-"You should shift your weight off your buttocks at intervals
throughout the day."
-"You should be sure your legs are placed on the floor
prior to transferring."
-"Position yourself in the back of the wheelchair after
transferring."
-"Lock your brakes when you are sitting in the wheelchair."
- Answer-You should shift your weight off your buttocks at
intervals throughout the day
*The nurse should instruct the client to shift their weight to
relieve pressure on the sacral area at regular intervals
throughout the day. This action will increase circulation to
the tissues and prevent skin breakdown.
A wound, ostomy and continence nurse (WOCN) is
providing an in service to a group of nurses about
documentation of pressure injuries. Which of the following
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statements by one of the group members indicates an
understanding of the teaching?
-"Pressure injury documentation includes the location,
stage, measurements, and condition of the wound bed
and any drainage present."
-"Drainage from a pressure injury only needs to be
documented if a foul odor is present."
-"If the pressure injury is healing as expected,
documentation can be completed with every other
dressing change."
-"Pressure injuries found on the mucous membranes
should be documented as stage 1 pressure injuries." -
Answer-Pressure injury documentation includes location,
stage, measurements and condition of the wound bed and
any drainage present
*When documenting pressure injuries, the nurse should
include the location, stage, size, description of tissue,
color of the wound bed, condition of surrounding tissue,
appearance of wound edges, presence of undermining
and tunneling, and any foul odor present. The nurse
should also document the presence and characteristics of
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any wound drainage observed. Any reports of pain at the
wound site should also be documented.
A nurse is caring for 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 call for help. Which of the following
actions should the nurse take?
-Ask the client to bear down and cough.
-Ask another nurse to bring icepacks to apply to the
wound.
-Cover the client's wound with a sterile saline dressing.
-Place the client in high-Fowler's position. - 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.
Tissue Integrity ATI Exam Newest 2025/2026 Actual
Exam Complete 100 Questions And Correct Detailed
Answers (Verified Answers) |Already Graded A+/
Latest Exam!!!
A nurse is observing an assistant personnel (AP) care for
a client. Which of the following actions by the 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. - Answer-A. 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?
A. Cellulitis
B. Skin tears
C. Premature Wrinkling
D. Dermatitis - Answer-D. Dermatitis
,2|Page
A nurse is providing teaching to 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?
-"You should shift your weight off your buttocks at intervals
throughout the day."
-"You should be sure your legs are placed on the floor
prior to transferring."
-"Position yourself in the back of the wheelchair after
transferring."
-"Lock your brakes when you are sitting in the wheelchair."
- Answer-You should shift your weight off your buttocks at
intervals throughout the day
*The nurse should instruct the client to shift their weight to
relieve pressure on the sacral area at regular intervals
throughout the day. This action will increase circulation to
the tissues and prevent skin breakdown.
A wound, ostomy and continence nurse (WOCN) is
providing an in service to a group of nurses about
documentation of pressure injuries. Which of the following
,3|Page
statements by one of the group members indicates an
understanding of the teaching?
-"Pressure injury documentation includes the location,
stage, measurements, and condition of the wound bed
and any drainage present."
-"Drainage from a pressure injury only needs to be
documented if a foul odor is present."
-"If the pressure injury is healing as expected,
documentation can be completed with every other
dressing change."
-"Pressure injuries found on the mucous membranes
should be documented as stage 1 pressure injuries." -
Answer-Pressure injury documentation includes location,
stage, measurements and condition of the wound bed and
any drainage present
*When documenting pressure injuries, the nurse should
include the location, stage, size, description of tissue,
color of the wound bed, condition of surrounding tissue,
appearance of wound edges, presence of undermining
and tunneling, and any foul odor present. The nurse
should also document the presence and characteristics of
, 4|Page
any wound drainage observed. Any reports of pain at the
wound site should also be documented.
A nurse is caring for 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 call for help. Which of the following
actions should the nurse take?
-Ask the client to bear down and cough.
-Ask another nurse to bring icepacks to apply to the
wound.
-Cover the client's wound with a sterile saline dressing.
-Place the client in high-Fowler's position. - 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.
