ATI RN
Introduction to Professional Nursing Questions
Question 1 of 5
The nurse assesses a stage III pressure ulcer. The nurse has observed which of the following?
Correct Answer: B
Rationale: The correct answer is B because a stage III pressure ulcer is characterized by an open wound with subcutaneous tissue exposed. This indicates significant tissue damage, making it a distinguishing feature of a stage III ulcer. Choice A is incorrect because redness that persists when pressure is relieved is indicative of a stage I pressure ulcer. Choice C is incorrect as it describes a stage IV ulcer, not stage III. Choice D is incorrect as it describes a stage II ulcer, not stage III.
Question 2 of 5
A nurse is caring for an older client who exhibits dehydration-induced confusion. Which intervention by the nurse is best?
Correct Answer: C
Rationale: The correct answer is C: Increase the IV flow rate to 250 mL/hr. Dehydration-induced confusion requires prompt correction of fluid deficit. Increasing IV flow rate will help rehydrate the client more quickly, addressing the underlying cause of confusion. This intervention is directly related to resolving dehydration. A: Measuring intake and output every 4 hours is important for monitoring fluid balance but will not address dehydration promptly. B: Assessing the client further for fall risk is important but does not directly address the underlying cause of confusion. D: Placing the client in a high-Fowler position can help with respiratory issues but does not directly address dehydration-induced confusion.
Question 3 of 5
A patient’s 4 X 3-cm leg wound has a 0.4-cm black area in the center of the wound surrounded by yellow-green semiliquid material. Which dressing should the nurse apply to the wound?
Correct Answer: C
Rationale: The correct answer is C: Hydrocolloid dressing. This type of dressing is ideal for a wound with yellow-green semiliquid material, as it helps to maintain a moist environment which promotes wound healing. The black area in the center could indicate necrotic tissue, and the hydrocolloid dressing can help to facilitate autolytic debridement. Dry gauze dressing (A) would not be suitable as it can adhere to the wound bed, causing trauma during removal. Nonadherent dressing (B) may not provide adequate moisture for healing. Transparent film dressing (D) may not be ideal as it does not provide the same level of absorption and protection as a hydrocolloid dressing.
Question 4 of 5
The nurse assesses a patient on the second postoperative day after abdominal surgery to repair a perforated duodenal ulcer. Which finding is most important for the nurse to report to the surgeon?
Correct Answer: B
Rationale: The correct answer is B: Fine crackles audible at both lung bases. This finding is most important to report because it suggests potential respiratory complications like atelectasis or pneumonia, which are common postoperative issues. The nurse should report this immediately to prevent further respiratory deterioration. A: Tympanic temperature of 99.2°F is slightly elevated but not a critical finding postoperatively. C: Redness and swelling along the suture line are common signs of surgical healing and expected in the early postoperative period. D: 200 mL sanguineous fluid in the wound drain is within the expected range for the second postoperative day after abdominal surgery and does not indicate an immediate concern.
Question 5 of 5
A patient is receiving heparin therapy as part of the treatment for a pulmonary embolism. The nurse monitors the results of which laboratory test to check the drug‘s effectiveness?
Correct Answer: B
Rationale: The correct answer is B: Activated partial thromboplastin time (aPTT). This test is used to monitor heparin therapy as it measures the effectiveness of the drug in prolonging clotting time. By monitoring aPTT levels, the nurse can ensure that the patient is within the therapeutic range to prevent clot formation without increasing the risk of bleeding. A: Bleeding times do not specifically monitor the effectiveness of heparin therapy and can be affected by various factors. C: Prothrombin time/international normalized ratio (PT/INR) is used to monitor warfarin therapy, not heparin. D: Vitamin K levels are not directly related to heparin therapy and are more relevant in monitoring patients on warfarin therapy.