ATI: Tissue Integrity 2.0

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.

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

D. Dermatitis

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?

A. Hydrofiber

B. Alginate

C. Hydrogel

D. transparent film

C. Hydrogel

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?

A. Obtain the culture using a clean cotton applicator

B. Clean the wound with 0.9% sodium chloride

C. Collect drainage from the area surrounding the wound

D. Place the applicator in a dry vial until cultures are complete

B. Clean the wound with 0.9% sodium chloride

A nurse is caring for a client who has a portable wound bulb suction device and notes that the drainage bulb is 3/4 full. Which of the following actions should the nurse take?

A. decrease the drainage suction force

B. Place the bulb on a flat surface and measure the amount of drainage

C. Empty and measure the drainage

D. Kink the tubing to prevent further drainage

C. 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?

A. Hypertension

B. Increased blood glucose

C. Decreased WBC count

D. increased BUN

B. Increased blood glucose

A nurse is performing an admission skin assessment on a client and notes that the client has a stage 3 pressure injury to the coccyx. How should the nurse document the appearance of this pressure injury?

A. "Stage 3 pressure injury to the coccyx observed with full-thickness skin loss and visible adipose tissue."

B. "Stage 3 pressure injury to the coccyx observed with non-blanchable area of erythema."

C. "Stage 3 pressure injury to the coccyx observed with partial-thickness skin loss, wound ped p

A. "Stage 3 pressure injury to the coccyx observed with full-thickness skin loss and visible adipose tissue."

A nurse is teaching a newly licensed nurse about wound healing by secondary intention. Which of the following statements by the newly licensed nurse indicates an understanding of healing by secondary intention?

A. "This type of healing carries a lower risk of infection than others."

B. "This type of healing begins in the wound bed with the generation of granulation tissue."

C. "These wounds heal faster than those that heal by other processes."

D. "These wounds require a dry wound bed in order fo

B. "This type of healing begins in the wound bed with the generation of granulation tissue."

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 calls for help. Which of the following actions should the nurse take?

A. Ask the client to bear down and cough

B. Ask another nurse to bring ice packs to apply to the wound.

C. Cover the client's wound with a sterile saline dressing

D. Place the client in a high Fowler's position

C. Cover the client's wound with a sterile saline dressing

A nurse is providing teaching for a client who has a prescription for an alginate dressing for a wound. Which of the following statements by the client indicates an understanding of an alginate dressing?

A. "The dressing will need to be changed every 24 hours."

B. "This type of dressing is used in small wounds with small amounts of drainage."

C. This dressing may develop a foul-smelling, yellow, gelatinous film on its underside as bacteria are trapped."

D. "This type of dressing will need a seco

D. "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?

A. "I should expect a small separation along the incision line."

B. "If I feel like something popped, I should sit up in bed."

C. "I should report pain at my wound site."

D. "Recurrent vomiting is expected after surgery."

C. "I should report pain at my wound site."

A nurse has completed the Braden scale on four clients who are at risk for alterations in skin integrity. Which of the following clients should the nurse recognize as having the greatest risk for altered skin integrity?

A. A client who has a Braden Scale score of 9

B. A client who has a Braden Scale score of 23

C A client who has a Braden Scale score of 12

D. A client who has a Braden Scale score of 15

A. A client who has a Braden Scale score of 9

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?

A. A client who is incontinent and is taking a prescribed diuretic

B. A client who has a lower extremity fracture and uses the overhead bed trapeze to move

C. A client who is NPO for surgery and is receiving IV fluids

D. A client who has lung cancer and will be receiving their first radiation treatment

A. A client who is incontinent and is taking a prescribed diuretic

A nurse is teaching a client who has a pressure injury on their leg about proper nutrition to facilitate wound healing. Which of the following client statements indicates an understanding of the teaching?

A. "I should consume a diet high in carbohydrates."

B. "I should increase my protein intake."

C. "I should include fruit and vegetables with every meal."

D. "I should avoid meat products."

B. "I should increase my protein intake."

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."

A. "You should shift your weight off your buttocks at intervals throughout the day."

B. "You should be sure your legs are placed on the floor prior to transferring."

C. "Position yourself in the back of the wheelchair after transferring."

D. "Lock your brakes when you are sitting in the wheelchair."

A. "You should shift your weight off your buttocks at intervals throughout the day."

A nurse is planning care for an older client who is bedridden. Which of the following actions should the nurse include in the plan to prevent skin breakdown?

B. Tilt the client on their side at 30 degrees

A nurse is providing teaching to a client about staple removal. Which of the following statements should the nurse include in the teaching?

A. "Your staples will dissolve in about 4 weeks."

B. "You will need to be placed under general anesthesia for the staples to be removed."

C. "Staples are unlikely to become embedded in the skin, making removal simple."

D. "Your staples will be removed in about 2 weeks."

D. "Your staples will be removed in about 2 weeks."

A nurse is caring for a client who has a dime-sized stage 1 pressure injury located on the sacrum. Which of the following dressing types should the nurse use?

A. A hydrogel dressing

B. A wet gauze dressing

C. A transparent film

D. An alginate dressing

C. A transparent film

A nurse is teaching an AP about the skin of older adults. Which of the following statements by the AP indicates an understanding of the teaching?

A. "Skin changes cause the synthesis of Vitamin B to decrease with age."

B. "The layers of the skin become more detached with age."

C. "Older adult clients have more moisture in the skin, placing them at risk for maceration."

D. "The skin of older adults is thinner and has less subcutaneous padding over bony prominences."

D. "The skin of older adults is thinner and has less subcutaneous padding over bony prominences."

A nurse is providing discharge teaching to the caregiver for a client who has a stage 1 pressure injury to the sacrum. Which of the following instructions should be included to the caregiver to prevent further skin breakdown?

A. Be sure to keep the skin moist

B. Do not use pillows to support extremities

C. Flex the client's knees while in bed

D. Provide a firm mattress for the client

C. Flex the client's knees while in bed

A nurse in an outpatient clinic is assessing the incision site of a client who is 7 days postoperative. Which of the following findings should the nurse expect?

A. A red incision site with a small amount of exudate

B. A bright pink incision site that is absent of exudate

C. A pale pink incision site with a moderate amount of exudate

D. A white to silver incision site absent of exudate

B. A bright pink incision site that is absent of exudate

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?

A. "Pressure injury documentation includes the location, stage, measurements, and condition of the wound bed and any drainage present."

B. "Drainage from a pressure injury only needs to be documented if a foul odor is present."

C. "If the pressure injury is he

A. "Pressure injury documentation includes the location, stage, measurements, and condition of the wound bed and any drainage present."

A nurse is providing teaching to a newly licensed nurse about the functions of the skin. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?

A. "The skin is strongest during early childhood."

B. "The epidermis pads internal organs and structures."

C. The subcutaneous layer of the skin contains cells that contribute to skin and hair color."

D. "The skin assists in the regulation of body temperature."

D. "The skin assists in the regulation of body temperature."

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?

A. Dehiscence

B. Evisceration

C. Hematoma

D. Fistula

A. Dehiscence

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?

A. The epidermis contains cells that assist in systemic immune responses

B. Collagen and elastin fibers increase with age

C. The skin consists of four distinct layers

D. The dermis contains blood vessels that help nourish the epidermis

D. The dermis contains blood vessels that help nourish the epidermis