ATI RN
ATI Nur 231 Fundamentals Exam Questions
Extract:
Question 1 of 5
A 65-year-old post-operative patient presents with a sudden opening of their surgical abdominal wound. What is the most appropriate immediate nursing action to take for this patient experiencing wound dehiscence?
Correct Answer: B
Rationale: Apply a sterile saline dressing and notify the surgeon immediately: This is the most appropriate immediate action in the event of wound dehiscence. Applying a sterile saline dressing helps protect the exposed tissue and prevent infection, while notifying the surgeon is crucial for further evaluation and intervention. Wound dehiscence is a surgical emergency that requires prompt attention.
Question 2 of 5
A nurse is performing oral care for a client who is unconscious. Which of the following actions should the nurse take?
Correct Answer: D
Rationale: Turn the client to the side: Turning the client to the side is the best action as it helps prevent aspiration of secretions or fluids during oral care.
Question 3 of 5
A nurse is reviewing the laboratory results of a client who has a pressure ulcer. The nurse should identify an elevation in which of the following laboratory values as an indication that the client has developed an infection?
Correct Answer: B
Rationale: WBC count: An elevated white blood cell (WB
C) count is a classic indicator of infection. The body responds to infection by increasing the production of white blood cells to fight off pathogens. A significantly elevated WBC count, especially if accompanied by a shift to the left (an increase in immature neutrophils), suggests an acute inflammatory response and the presence of an infection, making this the correct answer.
Question 4 of 5
A nurse is admitting an older adult from Mumbai, India who is visiting family members in the US. Which of the following would be most appropriate for the nurse to say?
Correct Answer: C
Rationale: Can you tell me how your culture will impact the care I will give?: This approach demonstrates respect for the patient's cultural background and invites them to share their beliefs, values, and preferences. It allows for an open dialogue and helps the nurse understand how to provide culturally competent care tailored to the patient’s needs.
Question 5 of 5
A charge nurse is making client care assignments. Which of the following tasks should the nurse delegate to assistive personnel (AP)? (Select all that apply.)
Correct Answer: A,C,E
Rationale: Bathe a client who had an amputation 2 days ago: This task can be delegated to assistive personnel (AP). Feed a client who had a stroke 3 months ago: This task can be delegated to APs, provided that the client is stable. Assist a client to ambulate using a gait belt: This task can be delegated to APs.