TISSUE INTEGRITY ATI EXAM QUESTIONS AND
ANSWERS
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? - Answers -You should shift your weight off your buttocks at intervals
throughout the day
Rationale: 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 statements by
one of the group members indicates an understanding of the teaching? - Answers -
Pressure injury documentation includes location, stage, measurements and condition of
the wound bed and any drainage present
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? - Answers -Hydrogel
Rationale: can be used for debridement of wounds with necrotized tissue and eachars,
and causes minimal trauma to the healing wound bed. Hydrogels work differently than
other dressings in that they can provide moisture to or draw moisture away from the
wound dependent upon the needs of the wound.
A nurse in a dermatology clinic is developing a skin anatomy poster to display for
clients. Which of the following information should the nurse plan to include on the
poster? - Answers -The dermis contains blood vessels that help nourish the epidermis
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? - Answers -Empty and measure the drainage
Should be emptied at least every 8 hours or when its 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? - Answers -
Increased blood glucose
Rationale: The nurse should identify this as a potential manifestation of sepsis.
HYPOtension is a potential manifestation of sepsis.
, INCREASED WBC count is a potential manifestation of sepsis.
Increased BUN is an indication of impaired kidney function rather than sepsis.
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? - Answers -Dermatitis
Rationale: the nurse should monitor the infant for dermatitis. During infancy and early
childhood when the skin is immature dermatitis develops when the skin is exposed to
urine and feces. The infant will be at even greater risk for dermatitis due to the
frequency of stools.
A nurse is providing teaching for a client who has a prescription for alginate dressing for
a wound. Which of the following statements by the client indicates an understanding of
alginate dressing? - Answers -"This type of dressing will need 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? - Answers -"I should report pain at my wound site".
Rationale: reporting pain at the site can be an indication of infection, which can lead to
the client's incision to dehisce.
A nurse is observing an assistive personnel (AP) care for a client. Which of the following
actions by the AP places the client at risk for alterations in skin integrity? - Answers -
The AP places the client in high-Fowler's position
Rationale: Placing the client in high-Fowlers position increases the risk for shearing and
alterations in skin integrity. Shearing occurs when clients are sitting or lying on an
incline, such as sitting in a high-Fowler's position in bed. As the client sits, gravity pulls
deeper tissues like fat and muscle downward while the top layers of the skin are still in
contact with the surface. Shearing results in stretching and trauma to the blood and
lymphatic vessels.
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? - Answers -
Cover the client's wound with a sterile saline dressing
This prevents dressing from adhering to the tissue and protect the organs until the client
is taken back to surgery.
ANSWERS
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? - Answers -You should shift your weight off your buttocks at intervals
throughout the day
Rationale: 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 statements by
one of the group members indicates an understanding of the teaching? - Answers -
Pressure injury documentation includes location, stage, measurements and condition of
the wound bed and any drainage present
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? - Answers -Hydrogel
Rationale: can be used for debridement of wounds with necrotized tissue and eachars,
and causes minimal trauma to the healing wound bed. Hydrogels work differently than
other dressings in that they can provide moisture to or draw moisture away from the
wound dependent upon the needs of the wound.
A nurse in a dermatology clinic is developing a skin anatomy poster to display for
clients. Which of the following information should the nurse plan to include on the
poster? - Answers -The dermis contains blood vessels that help nourish the epidermis
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? - Answers -Empty and measure the drainage
Should be emptied at least every 8 hours or when its 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? - Answers -
Increased blood glucose
Rationale: The nurse should identify this as a potential manifestation of sepsis.
HYPOtension is a potential manifestation of sepsis.
, INCREASED WBC count is a potential manifestation of sepsis.
Increased BUN is an indication of impaired kidney function rather than sepsis.
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? - Answers -Dermatitis
Rationale: the nurse should monitor the infant for dermatitis. During infancy and early
childhood when the skin is immature dermatitis develops when the skin is exposed to
urine and feces. The infant will be at even greater risk for dermatitis due to the
frequency of stools.
A nurse is providing teaching for a client who has a prescription for alginate dressing for
a wound. Which of the following statements by the client indicates an understanding of
alginate dressing? - Answers -"This type of dressing will need 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? - Answers -"I should report pain at my wound site".
Rationale: reporting pain at the site can be an indication of infection, which can lead to
the client's incision to dehisce.
A nurse is observing an assistive personnel (AP) care for a client. Which of the following
actions by the AP places the client at risk for alterations in skin integrity? - Answers -
The AP places the client in high-Fowler's position
Rationale: Placing the client in high-Fowlers position increases the risk for shearing and
alterations in skin integrity. Shearing occurs when clients are sitting or lying on an
incline, such as sitting in a high-Fowler's position in bed. As the client sits, gravity pulls
deeper tissues like fat and muscle downward while the top layers of the skin are still in
contact with the surface. Shearing results in stretching and trauma to the blood and
lymphatic vessels.
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? - Answers -
Cover the client's wound with a sterile saline dressing
This prevents dressing from adhering to the tissue and protect the organs until the client
is taken back to surgery.
