ATI Engage Fundamentals – Tissue Integrity Module with Posttest Answers 100% Pass
Guaranteed
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." 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.<< correct answer >>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." 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
