WGU EXAM zm
Exam Solution zm
Tissue Integrity 2026 A+ GRADE ASSURED COMPLETE zm zm zm zm zm zm zm
SOLUTIONS AND VERIFIED ANSWERS (3D66E) zm zm zm zm
QUESTION 1 zm
When planning care for an older adult client who is at risk for developing pressure ul
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cers, what is the best option? Use a transfer device to lift the client up in bed. Apply c
zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm
ornstarch to keep sensitive skin areas dry. Massage the skin over the client's bony pr
zm zm zm zm zm zm zm zm zm zm zm zm zm zm
ominences. Elevate the head of the bed no more than 45°.zm zm zm zm zm zm zm zm zm zm
ANSWER
Use a transfer device to lift the client up in bed. Using a lifting device prevents dragging the client's
zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm z
mskin across the bed linens, which can cause abrasions. Apply cornstarch to keep sensitive skin areas
zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm
dry. Cornstarch and baby powder can create dry, gritty debris that can abrade sensitive skin. Massa
zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm
ge the skin over the client's bony prominences. Massaging the skin over bony prominences has no p
zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm
reventive value, and it can traumatize deep tissues. Elevate the head of the bed no more than 45°. K
zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm
eeping the head of the bed no higher than 30° helps minimize shearing forces. Higher elevations can
zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm
cause the skin to stick to the bed linens while deeper tissues slide downward.
zm zm zm zm zm zm zm zm zm zm zm zm zm zm
QUESTION 2 zm
For someone who is confined to bed, which is an action to be included in the plan? M
zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm
assage the client's red bony prominences. Assess the client's skin for increased coolne
zm zm zm zm zm zm zm zm zm zm zm zm
ss. Reposition the client every 2 hr. Keep the client's skin moist.
zm zm zm zm zm zm zm zm zm zm zm
ANSWER
Reposition the client every 2 hr. The nurse should change the client's position every 2 hr to stimula
zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm
te circulation and prevent pressure ulcers. Massage the client's red bony prominences. The nurse ma
zm zm zm zm zm zm zm zm zm zm zm zm zm zm
y cause deep tissue trauma by massaging red bony prominences. Assess the client's skin for increase
zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm
d coolness. The nurse should asses the client's skin for increased warmth. Keep the client's skin moi
zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm
st. The nurse should use moisturizers on dry skin but should keep the client's skin dry and free of
zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm
prolonged moisture or drainage to prevent skin breakdown.
zm zm zm zm zm zm zm
QUESTION 3 zm
, When providing discharge teaching for a client who had an excisional biopsy of a skin
zm zm zm zm zm zm zm zm zm zm zm zm zm zm z
mlesion, what should the nurse include? "Keep the dressing in place for at least 24 hou
zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm
rs." "Clean the incisional site daily after the dressing is removed." "Use hydrogen pero
zm zm zm zm zm zm zm zm zm zm zm zm zm
xide to clean the incisional site." "The sutures will be removed in 2 weeks."
zm zm zm zm zm zm zm zm zm zm zm zm zm
ANSWER
"Clean the incisional site daily after the dressing is removed." The nurse should instruct the client to
zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm
clean the incisional site daily after the dressing is removed. "Use hydrogen peroxide to clean the in
zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm
cisional site." The nurse should instruct the client to clean the incisional site with tap water or salin
zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm
e to remove any dried blood or crusts. "The sutures will be removed in 2 weeks." The nurse should
zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm z
minstruct the client that suture removal will take place in 7 to 10 days. "Keep the dressing in place f
zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm
or at least 24 hours." The nurse should instruct the client to keep the dressing dry and in place for
zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm
at least 8 hr.
zm zm zm
QUESTION 4 zm
A leg wound: full thickness with jagged edges and muscle tissue visible. How should t
zm zm zm zm zm zm zm zm zm zm zm zm zm zm
his be documented by the nurse? Abrasion Contusion Laceration Puncture
zm zm zm zm zm zm zm zm zm
ANSWER
Laceration Lacerations are open wounds of varying depths caused by a tearing of soft body tissues.
zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm
The edges are often jagged and irregular. Lacerations are often considered contaminated wounds bec
zm zm zm zm zm zm zm zm zm zm zm zm zm
ause of the introduction of bacteria or debris that can be in the wound. Puncture. A puncture is an
zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm
open wound usually caused by a sharp object that penetrates the skin leaving a small surface openi
zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm
ng. Contusion. A contusion is a closed wound; the result of a blunt force impact. The wound appears
zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm
ecchymotic (bruised) as a result of trauma to the vascular system. Abrasion. An abrasion is an ope
zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm
n wound that occurs when the skin is scraped or rubbed off, such as an injury resulting from a fall
zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm
in which the knees are scraped.
zm zm zm zm zm
QUESTION 5 zm
Pediculosis capitis: what instructions should be given to parents? Soak all combs and
zm zm zm zm zm zm zm zm zm zm zm zm zm
hairbrushes in alcohol. Inspect any dogs or cats at home for lice. Seal nonwashable ite
zm zm zm zm zm zm zm zm zm zm zm zm zm zm
ms in airtight plastic bags. Spray countertops and sinks with insecticide.
zm zm zm zm zm zm zm zm zm zm
ANSWER
Seal nonwashable items in airtight plastic bags. Parents should seal items they cannot wash, vacuum
zm zm zm zm zm zm zm zm zm zm zm zm zm zm
, or dry clean in airtight plastic bags for 14 days to kill any lice on them. Spray countertops and sin
zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm
ks with insecticide. Parents should not spray insecticides in the home because they can pose a hazar
zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm
d to children and pets. Cleaning hard surfaces with household cleaners or disinfectants is appropriat
zm zm zm zm zm zm zm zm zm zm zm zm zm zm
e. Soak all combs and hairbrushes in alcohol. Parents should soak all combs, brushes, and hair clips
zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm
in a commercial pediculicide (lice-
zm zm zm zm
killing product) for 1 hr or in boiling water for 10 min. Inspect any dogs or cats at home for lice. P
zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm
ets do not carry or transmit lice.
zm zm zm zm zm zm
QUESTION 6 zm
Exam Solution zm
Tissue Integrity 2026 A+ GRADE ASSURED COMPLETE zm zm zm zm zm zm zm
SOLUTIONS AND VERIFIED ANSWERS (3D66E) zm zm zm zm
QUESTION 1 zm
When planning care for an older adult client who is at risk for developing pressure ul
zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm
cers, what is the best option? Use a transfer device to lift the client up in bed. Apply c
zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm
ornstarch to keep sensitive skin areas dry. Massage the skin over the client's bony pr
zm zm zm zm zm zm zm zm zm zm zm zm zm zm
ominences. Elevate the head of the bed no more than 45°.zm zm zm zm zm zm zm zm zm zm
ANSWER
Use a transfer device to lift the client up in bed. Using a lifting device prevents dragging the client's
zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm z
mskin across the bed linens, which can cause abrasions. Apply cornstarch to keep sensitive skin areas
zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm
dry. Cornstarch and baby powder can create dry, gritty debris that can abrade sensitive skin. Massa
zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm
ge the skin over the client's bony prominences. Massaging the skin over bony prominences has no p
zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm
reventive value, and it can traumatize deep tissues. Elevate the head of the bed no more than 45°. K
zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm
eeping the head of the bed no higher than 30° helps minimize shearing forces. Higher elevations can
zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm
cause the skin to stick to the bed linens while deeper tissues slide downward.
zm zm zm zm zm zm zm zm zm zm zm zm zm zm
QUESTION 2 zm
For someone who is confined to bed, which is an action to be included in the plan? M
zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm
assage the client's red bony prominences. Assess the client's skin for increased coolne
zm zm zm zm zm zm zm zm zm zm zm zm
ss. Reposition the client every 2 hr. Keep the client's skin moist.
zm zm zm zm zm zm zm zm zm zm zm
ANSWER
Reposition the client every 2 hr. The nurse should change the client's position every 2 hr to stimula
zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm
te circulation and prevent pressure ulcers. Massage the client's red bony prominences. The nurse ma
zm zm zm zm zm zm zm zm zm zm zm zm zm zm
y cause deep tissue trauma by massaging red bony prominences. Assess the client's skin for increase
zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm
d coolness. The nurse should asses the client's skin for increased warmth. Keep the client's skin moi
zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm
st. The nurse should use moisturizers on dry skin but should keep the client's skin dry and free of
zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm
prolonged moisture or drainage to prevent skin breakdown.
zm zm zm zm zm zm zm
QUESTION 3 zm
, When providing discharge teaching for a client who had an excisional biopsy of a skin
zm zm zm zm zm zm zm zm zm zm zm zm zm zm z
mlesion, what should the nurse include? "Keep the dressing in place for at least 24 hou
zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm
rs." "Clean the incisional site daily after the dressing is removed." "Use hydrogen pero
zm zm zm zm zm zm zm zm zm zm zm zm zm
xide to clean the incisional site." "The sutures will be removed in 2 weeks."
zm zm zm zm zm zm zm zm zm zm zm zm zm
ANSWER
"Clean the incisional site daily after the dressing is removed." The nurse should instruct the client to
zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm
clean the incisional site daily after the dressing is removed. "Use hydrogen peroxide to clean the in
zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm
cisional site." The nurse should instruct the client to clean the incisional site with tap water or salin
zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm
e to remove any dried blood or crusts. "The sutures will be removed in 2 weeks." The nurse should
zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm z
minstruct the client that suture removal will take place in 7 to 10 days. "Keep the dressing in place f
zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm
or at least 24 hours." The nurse should instruct the client to keep the dressing dry and in place for
zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm
at least 8 hr.
zm zm zm
QUESTION 4 zm
A leg wound: full thickness with jagged edges and muscle tissue visible. How should t
zm zm zm zm zm zm zm zm zm zm zm zm zm zm
his be documented by the nurse? Abrasion Contusion Laceration Puncture
zm zm zm zm zm zm zm zm zm
ANSWER
Laceration Lacerations are open wounds of varying depths caused by a tearing of soft body tissues.
zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm
The edges are often jagged and irregular. Lacerations are often considered contaminated wounds bec
zm zm zm zm zm zm zm zm zm zm zm zm zm
ause of the introduction of bacteria or debris that can be in the wound. Puncture. A puncture is an
zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm
open wound usually caused by a sharp object that penetrates the skin leaving a small surface openi
zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm
ng. Contusion. A contusion is a closed wound; the result of a blunt force impact. The wound appears
zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm
ecchymotic (bruised) as a result of trauma to the vascular system. Abrasion. An abrasion is an ope
zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm
n wound that occurs when the skin is scraped or rubbed off, such as an injury resulting from a fall
zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm
in which the knees are scraped.
zm zm zm zm zm
QUESTION 5 zm
Pediculosis capitis: what instructions should be given to parents? Soak all combs and
zm zm zm zm zm zm zm zm zm zm zm zm zm
hairbrushes in alcohol. Inspect any dogs or cats at home for lice. Seal nonwashable ite
zm zm zm zm zm zm zm zm zm zm zm zm zm zm
ms in airtight plastic bags. Spray countertops and sinks with insecticide.
zm zm zm zm zm zm zm zm zm zm
ANSWER
Seal nonwashable items in airtight plastic bags. Parents should seal items they cannot wash, vacuum
zm zm zm zm zm zm zm zm zm zm zm zm zm zm
, or dry clean in airtight plastic bags for 14 days to kill any lice on them. Spray countertops and sin
zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm
ks with insecticide. Parents should not spray insecticides in the home because they can pose a hazar
zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm
d to children and pets. Cleaning hard surfaces with household cleaners or disinfectants is appropriat
zm zm zm zm zm zm zm zm zm zm zm zm zm zm
e. Soak all combs and hairbrushes in alcohol. Parents should soak all combs, brushes, and hair clips
zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm
in a commercial pediculicide (lice-
zm zm zm zm
killing product) for 1 hr or in boiling water for 10 min. Inspect any dogs or cats at home for lice. P
zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm
ets do not carry or transmit lice.
zm zm zm zm zm zm
QUESTION 6 zm
