ATI Engage Fundamentals: Tissue Integrity- Posttest questions and answers correct/ ATI-Engage Fundamentals: Tissue Integrity exam questions and answers (recommended by proffesors)latest

ATI Engage Fundamentals: Tissue Integrity- Posttest questions and answers correct/ ATI-Engage Fundamentals: Tissue Integrity exam questions and answers (recommended by proffesors)latest ATI Engage Fundamentals: Tissue Integrity- Posttest questions and answers correct/ ATI-Engage Fundamentals: Tissue Integrity exam questions and answers (recommended by proffesors)latest ATI Engage Fundamentals: Tissue Integrity- Posttest questions and answers correct/ ATI-Engage Fundamentals: Tissue Integrity exam questions and answers (recommended by proffesors)latest 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? - correct answers-You should shift your weight off your buttocks at intervals throughout the day 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? - correct 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 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? - correct answers-Cover the client's wound with a sterile saline dressing A nurse is teaching assistive personnel (AP) about the skin of older adults. Which of the following statements by the AP indicates an understanding of the teaching? - correct answers-The skin of older adults is thinner and has less subcutaneous padding over bony prominences 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? - correct answers-Clean the wound with 0.9% sodium chloride A nurse is assisting with the care of a client following abdominal surgery. The nurse removes the client's surgical dressing and notes a separation of the wound edges. The nurse should identify that the client is experiencing which of the following complications? - correct answers-Dehiscence A nurse is providing teaching to a client about staple removal. Which of the following statements should the nurse include in the teaching? - correct answers-Your staples will be removed in about 2 weeks A nurse is caring for a group of clients. Which of the following clients should the nurse identify as having the highest risk for developing alterations in tissue integrity? - correct answers-A client who is incontinent and taking a prescribed diuretic A nurse is caring for a client who has dime-sized stage 1 pressures injury located on the sacrum. Which of the following dressing types should the nurse use? - correct answers-A transparent film A nurse is providing teachATI-Engage Fundamentals: Tissue Integrity 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? -"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." - correct answers-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 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." - correct answers-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 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. - correct answers-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. A nurse is teaching assistive personnel (AP) about the skin of older adults. Which of the following statements by the AP indicates an understanding of the teaching? -"Skin changes cause the synthesis of vitamin B to decrease with age." -"The layers of the skin become detached with age." -"Older adult clients have more moisture in the skin, placing them at risk for maceration." -"The skin of older adults is thinner and has less subcutaneous padding over bony prominences." - correct answers-The skin of older adults is thinner and has less subcutaneous padding over bony prominences *As an individual ages, expected changes occur in the skin, including a decrease in elasticity and subcutaneous tissue. This increases the risk of injury to the skin for older adults. 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? -Obtain the culture using a clean cotton applicator. -Clean the wound with 0.9% sodium chloride. -Collect drainage from the area s