TISSUE INTEGRITY ATI EXAMINATION TEST 2025/2026
QUESTIONS AND ANSWERS GRADED A+
✔✔30.A nurse is changing the dressing of a client who is 1 week postoperative
following abdominal surgery and notes
the presence of serosanguineous drainage. The nurse should recognize that this is an
indication of which of the
following circumstances?
A. Serosanguineous drainage at this time is expected after abdominal surgery.
B. Serosanguineous drainage at this time is a manifestation of possible dehiscence.
C. Serosanguineous drainage at this time is a manifestation of hemorrhage.
D. Serosanguineous drainage at this time is a manifestation of infection. - ✔✔B.
Serosanguineous drainage at this time is a manifestation of possible dehiscence.
Rationale:Serosanguineous drainage beyond the fifth postoperative day is a
manifestation of possible
dehiscence and the provider should be notified.
✔✔31.A nurse is caring for an infant who has diaper dermatitis. Which of the following
actions should the nurse take?
A. Apply a light layer of talcum powder with each diaper change.
B. Change to cloth diapers until the skin is healed.
C. Expose the excoriated area to hot air frequently.
D. Use a moisturizer to wipe urine from the skin. - ✔✔D. Use a moisturizer to wipe urine
from the skin.
Rationale:It is appropriate for the nurse to use a moisturizer to wipe urine from the skin.
This will prevent
further breakdown of the skin.
✔✔32.A nurse is completing a client assessment for admission to the medical unit.
Which of the following abdominal
assessment findings require further investigation by the nurse?
A. Symmetrical convex sphere shape
B. Concave umbilicus
C. Bilateral bowel sounds in lower quadrants
D. Ecchymosis - ✔✔D. Ecchymosis
Rationale:Ecchymosis is a finding outside of the expected reference range for an
abdominal assessment
and would require the nurse to further investigate for potential injury, bleeding disorder,
or
physical abuse.
✔✔33.A nurse is developing a plan of care for a client who has a stage 3 pressure
ulcer. Which of the following
interventions should the nurse include in the plan?
A. Apply a heat lamp twice a day.
, B. Reposition the client at least every 2 hr.
C. Clean the wound with hydrogen peroxide solution.
D. Massage reddened areas with dressing changes. - ✔✔B. Reposition the client at
least every 2 hr.
Rationale: The nurse should plan to reposition the client at least every 2 hr and to make
a schedule to
record position changes for the client's medical record.
✔✔34.A nurse is preparing to discharge a client who has an abdominal wound that is
healing by secondary intention.
Which of the following actions is the nurse's priority?
A. Instruct the client about home disposal of contaminated dressings.
B. Schedule a follow-up visit by a home health nurse for dressing changes.
C. Provide a dietary list of foods which promote wound healing.
D. Establish a follow-up appointment with the client's provider - ✔✔B. Schedule a
follow-up visit by a home health nurse for dressing changes.
Rationale: The greatest risk to this client is injury from a wound infection. Therefore, the
priority action the
nurse should take is to schedule a follow-up visit by a home health nurse for dressing
changes.
Wounds healing by secondary intention are open and have edges that are not
approximated,
which increases the risk for infection.
✔✔35.A nurse is caring for a client who has urinary incontinence. Which of the following
actions should the nurse
implement to prevent the development of skin breakdown?
A. Apply a moisture barrier ointment to the client's skin.
B. Clean the client's skin and perineum with hot water after each episode of
incontinence.
C. Check the client's skin every 8 hr for signs of breakdown.
D. Request a prescription for the insertion of an indwelling urinary catheter. - ✔✔A.
Apply a moisture barrier ointment to the client's skin.
Rationale:Skin that remains in contact with urine for prolonged periods is at risk for
maceration and
breakdown. After cleansing and drying the client's skin, the nurse should apply a
moisture
barrier ointment to prevent further contact of the skin with urine.
✔✔36.A nurse is providing dietary teaching for a client who has a burn injury and
adheres to a vegan diet. The nurse
should recommend which of the following foods as the best source of protein to promote
wound healing?
A. One cup of brown rice
B. One cup of orange juice
C. One cup of pureed avocado
QUESTIONS AND ANSWERS GRADED A+
✔✔30.A nurse is changing the dressing of a client who is 1 week postoperative
following abdominal surgery and notes
the presence of serosanguineous drainage. The nurse should recognize that this is an
indication of which of the
following circumstances?
A. Serosanguineous drainage at this time is expected after abdominal surgery.
B. Serosanguineous drainage at this time is a manifestation of possible dehiscence.
C. Serosanguineous drainage at this time is a manifestation of hemorrhage.
D. Serosanguineous drainage at this time is a manifestation of infection. - ✔✔B.
Serosanguineous drainage at this time is a manifestation of possible dehiscence.
Rationale:Serosanguineous drainage beyond the fifth postoperative day is a
manifestation of possible
dehiscence and the provider should be notified.
✔✔31.A nurse is caring for an infant who has diaper dermatitis. Which of the following
actions should the nurse take?
A. Apply a light layer of talcum powder with each diaper change.
B. Change to cloth diapers until the skin is healed.
C. Expose the excoriated area to hot air frequently.
D. Use a moisturizer to wipe urine from the skin. - ✔✔D. Use a moisturizer to wipe urine
from the skin.
Rationale:It is appropriate for the nurse to use a moisturizer to wipe urine from the skin.
This will prevent
further breakdown of the skin.
✔✔32.A nurse is completing a client assessment for admission to the medical unit.
Which of the following abdominal
assessment findings require further investigation by the nurse?
A. Symmetrical convex sphere shape
B. Concave umbilicus
C. Bilateral bowel sounds in lower quadrants
D. Ecchymosis - ✔✔D. Ecchymosis
Rationale:Ecchymosis is a finding outside of the expected reference range for an
abdominal assessment
and would require the nurse to further investigate for potential injury, bleeding disorder,
or
physical abuse.
✔✔33.A nurse is developing a plan of care for a client who has a stage 3 pressure
ulcer. Which of the following
interventions should the nurse include in the plan?
A. Apply a heat lamp twice a day.
, B. Reposition the client at least every 2 hr.
C. Clean the wound with hydrogen peroxide solution.
D. Massage reddened areas with dressing changes. - ✔✔B. Reposition the client at
least every 2 hr.
Rationale: The nurse should plan to reposition the client at least every 2 hr and to make
a schedule to
record position changes for the client's medical record.
✔✔34.A nurse is preparing to discharge a client who has an abdominal wound that is
healing by secondary intention.
Which of the following actions is the nurse's priority?
A. Instruct the client about home disposal of contaminated dressings.
B. Schedule a follow-up visit by a home health nurse for dressing changes.
C. Provide a dietary list of foods which promote wound healing.
D. Establish a follow-up appointment with the client's provider - ✔✔B. Schedule a
follow-up visit by a home health nurse for dressing changes.
Rationale: The greatest risk to this client is injury from a wound infection. Therefore, the
priority action the
nurse should take is to schedule a follow-up visit by a home health nurse for dressing
changes.
Wounds healing by secondary intention are open and have edges that are not
approximated,
which increases the risk for infection.
✔✔35.A nurse is caring for a client who has urinary incontinence. Which of the following
actions should the nurse
implement to prevent the development of skin breakdown?
A. Apply a moisture barrier ointment to the client's skin.
B. Clean the client's skin and perineum with hot water after each episode of
incontinence.
C. Check the client's skin every 8 hr for signs of breakdown.
D. Request a prescription for the insertion of an indwelling urinary catheter. - ✔✔A.
Apply a moisture barrier ointment to the client's skin.
Rationale:Skin that remains in contact with urine for prolonged periods is at risk for
maceration and
breakdown. After cleansing and drying the client's skin, the nurse should apply a
moisture
barrier ointment to prevent further contact of the skin with urine.
✔✔36.A nurse is providing dietary teaching for a client who has a burn injury and
adheres to a vegan diet. The nurse
should recommend which of the following foods as the best source of protein to promote
wound healing?
A. One cup of brown rice
B. One cup of orange juice
C. One cup of pureed avocado
