ATI RN
ATI Fundamentals Exam Nursing 100 Exam 3 Questions
Extract:
Question 1 of 5
A nurse in a PACU is assessing a client who has a newly created colostomy. Which of the following findings should the nurse report to the provider?
Correct Answer: A
Rationale:
Step 1: A purplish-colored stoma indicates poor blood flow, which can lead to tissue necrosis and potential stoma complications.
Step 2: This finding should be reported promptly to the provider for further evaluation and intervention to prevent serious complications. Summary: B (shiny, moist stoma) is a normal finding indicating good tissue hydration; C (stoma oozing red drainage) may be expected postoperatively; D (budded stoma) is not a recognized term in stoma assessment.
Question 2 of 5
The nurse moves a client's arm from an outstretched position to a position at the side of his body. What is the term used to describe this type of body movement?
Correct Answer: B
Rationale: The correct answer is B: Adduction. Adduction refers to moving a body part towards the midline of the body. When the nurse moves the client's arm from an outstretched position to the side of the body, she is bringing the arm closer to the midline, which is adduction. Extension (choice
A) is the opposite movement, where a body part is moved away from the midline. Circumduction (choice
C) is a circular movement involving flexion, extension, abduction, and adduction, which is not the case here. Abduction (choice
D) is moving a body part away from the midline, which is the opposite of what is described in the scenario.
Question 3 of 5
A nurse is caring for a client and observes that the client's urine is dark amber,cloudy and has an unpleasant odor. The nurse should recognize that these findings are associated with which of the following?
Correct Answer: A
Rationale: The correct answer is A: Urinary tract infection (UTI). Dark amber, cloudy, and foul-smelling urine are common symptoms of a UTI due to the presence of bacteria and pus in the urine. The cloudy appearance is caused by the presence of white blood cells and bacteria. The unpleasant odor is a result of the bacterial growth in the urinary tract. Additionally, UTIs are often associated with symptoms such as burning sensation during urination and frequency.
Summary of other choices:
B: Urinary retention typically presents with the inability to completely empty the bladder, not changes in urine color or odor.
C: Urinary incontinence refers to the involuntary loss of urine, not changes in urine appearance or smell.
D: Urinary frequency is the need to urinate more often than usual, not directly related to changes in urine characteristics.
Question 4 of 5
A nurse is caring for a client who has urinary incontinence. Which of the following actions should the nurse implement to prevent the development of skin breakdown?
Correct Answer: B
Rationale:
Correct
Answer: B - Apply a moisture barrier ointment to the client's skin
Rationale: Applying a moisture barrier ointment creates a protective barrier on the skin, preventing irritation and breakdown from prolonged exposure to moisture. This is crucial in managing urinary incontinence to maintain skin integrity.
Summary of other choices:
A: Requesting a urinary catheter may increase the risk of infection and skin breakdown.
C: Cleaning with hot water can strip the skin of natural oils, leading to further skin irritation.
D: Checking the skin every 8 hours is important but not as effective as preventing breakdown with a moisture barrier ointment.
Question 5 of 5
A nurse is assessing a client who is experiencing complications due to immobility. Which of the following findings should the nurse expect? (Select All that Apply.)
Correct Answer: A,D,E
Rationale: The correct answer is A, D, and E.
- Contractures can occur due to prolonged immobility, leading to muscle shortening.
- Atelectasis, a condition where alveoli in the lungs collapse, can result from decreased lung expansion.
- Pressure ulcers are common in immobile clients due to prolonged pressure on skin and tissue.
B: Diarrhea is not directly related to immobility but may be due to other causes like infections or medications.
C: Polyuria, excessive urination, is not typically associated with immobility complications.
In summary, contractures, atelectasis, and pressure ulcers are common findings in clients experiencing complications due to immobility, while diarrhea and polyuria are not directly related to immobility.