ATI RN
ATI Fundamentals Exam Special Unit ADN Questions
Extract:
Question 1 of 5
A nurse is administering nasal decongestant drops for a client. Which of the following actions should the nurse take?
Correct Answer: A
Rationale: Tell the client to blow his/her nose gently before the instillation of the drops: Blowing the nose clears the nasal passages, allowing the medication to reach the mucosa effectively. Assist the client to a side-lying position: The correct position is head tilted backward (supine with neck hyperextended) or head tilted slightly to the side to ensure proper absorption. A side-lying position is not appropriate for nasal drops. Hold the dropper 2 cm (1 inch) above the nares: The dropper should be placed just inside the nostril without touching it to prevent contamination. Holding it too high may cause the drops to miss the nasal mucosa. Instruct the client to stay in the same position for 2 minutes: Remaining in position for at least 5 minutes allows the medication to be absorbed without draining out of the nasal cavity.
Question 2 of 5
A nurse is reviewing the electrocardiogram (ECG) results. Which portion of the conduction system does the nurse consider when evaluating the P wave?
Correct Answer: B
Rationale: SA Node: The SA (sinoatrial) node initiates electrical impulses and is responsible for atrial depolarization, which produces the P wave on an ECG. This makes it the correct answer. AV Node: The AV node is responsible for delaying electrical impulses before they pass to the ventricles, but it does not generate the P wave. It affects the PR interval rather than the P wave itself. Purkinje Fibers: The Purkinje fibers play a role in ventricular contraction (QRS complex), not in the formation of the P wave. Bundle of HIS: The Bundle of HIS transmits impulses to the ventricles and is involved in ventricular depolarization, not atrial activity. It is not responsible for the P wave.
Question 3 of 5
A nurse is preparing to perform hand hygiene. Which of the following actions should the nurse take?
Correct Answer: C
Rationale: Apply 4 to 5 mL of liquid soap to the hands: The recommended amount of liquid soap is 3 to 5 mL to effectively remove microorganisms. Using too little may not clean adequately, and using too much can make rinsing difficult. Hold the hands higher than the elbows: Hands should be held lower than the elbows to allow water to flow from the fingertips downward, preventing contamination of clean areas by dirty water. Rub hands and arms to dry: Hands should be dried by patting rather than rubbing to prevent skin irritation. Also, drying should focus on the hands first, then the wrists, and then the forearms to avoid recontamination. Adjust the water temperature to feel hot: Water should be warm, not hot, to prevent skin irritation and dryness. Hot water can damage the skin’s natural protective barrier, increasing susceptibility to infection.
Question 4 of 5
Which item should the nurse use first to assist in staging an ulcer on the heel of a darkly pigmented skin patient?
Correct Answer: C
Rationale: Natural light: In darkly pigmented skin, color changes may not be obvious under artificial lighting. Using natural light helps the nurse detect early signs of skin breakdown. Disposable measuring tape: While measuring the wound is important, assessing the wound’s color and depth should be the first step to determine staging. Cotton-tipped applicator: A cotton-tipped applicator is useful for assessing undermining or tunneling, but it is not the first step in staging a pressure ulcer. Sterile gloves: Gloves are necessary for infection control, but they do not assist in staging the ulcer. First, assess the wound using natural light.
Question 5 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.