Exam (elaborations)
ATI ENGAGE FUNDAMENTALS: TISSUE INTEGRITY- POSTTEST
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ATI ENGAGE FUNDAMENTALS: TISSUE INTEGRITY- POSTTEST
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ATI ENGAGE FUNDAMENTALS: TISSUE INTEGRITY-POSTTEST
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
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 planning care for an older adult clients who is bedridden. Which of the
following actions should the nurse include in the plan to prevent skin breakdown? -
Answers -Tilt the client on their side at 30 degrees
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
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
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
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
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".
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