ATI RN
ATI RN Fundamental Proctored Exam With NGN Graded Questions
Extract:
Question 1 of 5
A nursing instructor is reviewing the wound healing process with a group of nursing students. They should be able to identify which of the following alterations as a wound or injury that heals by secondary intention? Select all.
Correct Answer: A, E
Rationale: The correct answers are A and E because wounds healing by secondary intention involve tissue loss and heal from the bottom up with granulation tissue filling in the wound. A Stage III pressure ulcer and an open burn area are examples of wounds that heal by secondary intention due to tissue loss.
Choices B and D are incorrect because sutured surgical incisions and lacerations sealed with adhesive heal by primary intention, where wound edges are approximated and heal with minimal scarring.
Choice C, a casted bone fracture, is incorrect as fractures heal through a different process involving the formation of callus and subsequent bone remodeling, not by secondary intention healing.
Question 2 of 5
A client who had abdominal surgery 24 hr ago reports a pulling sensation & pain in his surgical incision. The nurse checks the client's surgical wound and finds the wound separated with viscera protruding. Which of the following interventions is appropriate? Select all.
Correct Answer: A, D
Rationale:
Correct
Answer: A, D
Rationale:
1. Covering the area with saline-soaked sterile dressings (
Choice
A) helps to protect the exposed tissues, prevent infection, and maintain a moist environment for healing.
2. Positioning the client supine with hips and knees bent (
Choice
D) can help reduce tension on the wound, alleviate pain, and minimize the risk of further tissue damage.
Summary:
- Applying an abdominal binder (
Choice
B) may increase pressure on the wound, exacerbating the situation.
- Using sterile gloves to apply pressure to exposed tissues (
Choice
C) can introduce contamination and should be avoided.
- Offering a warm beverage (
Choice E) is irrelevant and does not address the urgent need to manage the wound.
Question 3 of 5
A nurse is caring for an older adult client who is at risk for developing pressure ulcers. Which of the following interventions should the nurse use to help maintain the integrity of the client's skin? Select all.
Correct Answer: A, D
Rationale: The correct interventions (A and
D) are crucial for preventing pressure ulcers in older adults. Elevating the head of the bed at 30 degrees helps reduce pressure on the sacrum and heels, key areas prone to pressure ulcers. Sitting on a gel cushion distributes pressure evenly, reducing the risk of skin breakdown.
Incorrect
Choices:
B: Massaging bony prominences can increase friction and shear forces, leading to skin breakdown.
C: Cornstarch can create a moist environment, increasing the risk of maceration and skin breakdown.
E: Repositioning every 3 hours is insufficient for preventing pressure ulcers, as more frequent repositioning is needed to reduce prolonged pressure on the skin.
Question 4 of 5
A nurse on a med-surg unit has received change-of-shift report & will care for 4 clients. Which of the following client's needs may the nurse assign to assistive personnel (AP)?
Correct Answer: C
Rationale: The correct answer is C because reapplying a condom catheter for a client with urinary incontinence is a task that can be safely delegated to assistive personnel (AP). This task involves a straightforward procedure that does not require advanced nursing skills or critical thinking. The nurse can provide clear instructions and oversee the AP's performance.
Choice A is incorrect because feeding a client with aspiration pneumonia requires close monitoring by a nurse due to the risk of complications.
Choice B is incorrect as reinforcing teaching for a client learning to walk with a quad cane involves assessing the client's understanding and progress, which is within the nurse's scope.
Choice D is incorrect because applying a sterile dressing to a pressure ulcer requires sterile technique and assessment of wound healing, which should be done by a nurse.
Question 5 of 5
A nurse is delegating the ambulation of a client who had knee arthroplasty 5 days ago to an AP. Which of the following information should the nurse share with the AP?
Correct Answer: B, C, D
Rationale:
Correct
Answer: B, C, D
Rationale:
- Option B: The client should not wear slippers over antiembolic stockings as it can increase the risk of slipping or falling.
- Option C: Knowing that the client uses a front-wheeled walker is crucial for safe ambulation post-knee arthroplasty.
- Option D: Advising on the timing of pain medication helps ensure the client is comfortable during ambulation.
Summary:
- Option A is incorrect because the roommate's ambulation status is irrelevant to the client's care.
- Option E is incorrect as the client's allergy to codeine does not directly impact safe ambulation post-knee arthroplasty.