ATI RN
ATI Fundamentals Exam Special Unit ADN Questions
Question 1 of 5
While performing an assessment, the nurse hears crackles in the patient's lung fields. The nurse also learns that the patient is sleeping on three pillows to help with the difficulty breathing during the night. Which condition will the nurse most likely observe written in the patient's medical record?
Correct Answer: A
Rationale: Left-sided heart failure: Left-sided heart failure causes pulmonary congestion leading to crackles, orthopnea (difficulty breathing while lying flat), and paroxysmal nocturnal dyspnea (waking up gasping for air). Myocardial ischemia: Myocardial ischemia causes chest pain, shortness of breath, and fatigue, but it does not cause crackles in the lungs or fluid overload symptoms. Right-sided heart failure: Right-sided heart failure results in systemic congestion (peripheral edema, weight gain, and jugular vein distention), not pulmonary symptoms like crackles. Atrial fibrillation: Atrial fibrillation causes irregular heartbeats, palpitations, and fatigue, but it is not the primary cause of crackles or orthopnea.
Question 2 of 5
A patient has been diagnosed with heart failure and cardiac output is decreased. Which formula can the nurse use to calculate cardiac output?
Correct Answer: C
Rationale: Stroke volume × heart rate: Cardiac Output (CO) = Stroke Volume (SV) × Heart Rate (HR). Stroke volume is the amount of blood pumped per beat, and heart rate is the number of beats per minute. Multiplying these values gives the total volume of blood pumped per minute, making this the correct formula. Myocardial contractility × myocardial blood flow: While myocardial contractility and blood flow affect cardiac output, they are not part of the formula for calculating it. Ventricular filling time/diastolic filling time: This ratio does not determine cardiac output. While diastolic filling time affects stroke volume, it is not the standard formula for cardiac output. Preload/afterload: Preload and afterload influence cardiac function but are not used to directly calculate cardiac output.
Question 3 of 5
A nurse is providing preoperative teaching by demonstrating diaphragmatic breathing to a client who is scheduled for surgery in the morning. Which of the following actions should the nurse include in the demonstration?
Correct Answer: D
Rationale: Inhale slowly and evenly through her nose: The correct technique for diaphragmatic breathing is to inhale deeply through the nose while the abdomen expands. This promotes lung expansion and prevents atelectasis postoperatively. Hold her breath for at least 10 seconds: Diaphragmatic breathing focuses on slow, deep breaths to promote lung expansion and oxygenation. Holding the breath is not part of this technique and may increase discomfort. Place her hands on the sides of her rib cage: While hand placement is encouraged, the correct position is on the abdomen (below the rib cage), not the sides. This helps the client feel the diaphragm expanding. Exhale forcefully through the nose: Exhalation should be slow and controlled through the mouth, not forceful through the nose, to prevent airway irritation.
Question 4 of 5
The nurse admitting an older patient notes a shallow open reddish, pink ulcer without slough on the right heel of the patient. How will the nurse stage this pressure ulcer?
Correct Answer: D
Rationale: Stage II: Stage II pressure ulcers involve partial-thickness skin loss with a shallow open wound, pink/red wound bed, and no slough. The given description matches Stage II. Stage IV: Stage IV ulcers involve full-thickness skin loss with exposed bone, tendon, or muscle. Since this ulcer is shallow and pink without slough, it is not Stage IV. Stage I: Stage I ulcers are intact skin with non-blanchable erythema. Since the ulcer is open, it is not Stage I. Stage III: Stage III ulcers have full-thickness tissue loss, possibly exposing subcutaneous fat. The given description lacks fat exposure or depth, ruling out Stage III.
Question 5 of 5
The nurse is preparing to assess the blood pressure of a 3-year-old. How should the nurse proceed?
Correct Answer: A
Rationale: Explain the procedure to the child: Explaining procedures in an age-appropriate manner helps reduce anxiety and increases cooperation. A 3-year-old can understand simple instructions, so explaining what will happen can help them remain calm. Choose the cuff that says 'Child' instead of 'Infant': Blood pressure cuffs should be appropriately sized for accurate readings. A cuff that is too small can result in falsely high readings, while a cuff that is too large can produce falsely low readings. Use the diaphragm portion of the stethoscope to detect Korotkoff sounds: The bell of the stethoscope is best for detecting low-pitched sounds, including Korotkoff sounds. Obtain the reading before the child has a chance to settle down: A child who is upset, crying, or anxious may have an elevated blood pressure reading due to stress. It is best to allow the child to calm down before obtaining an accurate measurement.