ATI RN
ATI Nursing 100 Day Exam 4 Fundamentals Questions
Extract:
Question 1 of 5
A nurse is admitting a patient who has a DTI (deep tissue injury) to the hospital. The nurse understands that a DTI:
Correct Answer: A
Rationale: DTI results from pressure or shear (tissue layers sliding) causing deep tissue damage often under intact skin. Dressing frequency varies by wound overhydration does not cause DTI and it is not partial thickness but involves deeper layers like muscle or fat.
Question 2 of 5
When doing the client's skin assessment the nurse notes a 3 cm area of partial thickness skin loss that looks like a blister on the client's sacral area. The nurse consults the wound care nurse who stages the wound as a pressure ulcer.
Correct Answer: B
Rationale: Partial thickness skin loss appearing as a blister indicates a Stage II pressure ulcer involving the epidermis and dermis. Stage I is intact skin with redness Stage III involves full-thickness loss and Stage IV includes deep tissue damage like muscle or bone.
Question 3 of 5
The nurse notes that a diuretic is listed on the client's medication administration record (MAR). It is most important for the nurse to report to the physician a serum:
Correct Answer: B
Rationale: A low potassium level (3.2 mEq/L below normal 3.5-5.0 mEq/L) indicates hypokalemia a serious diuretic side effect risking arrhythmias and requiring immediate reporting. Normal sodium (135-145 mEq/L) hematocrit (38-50%) and chloride (95-105 mEq/L) levels are less urgent.
Question 4 of 5
A group that has transformed itself from a collection of individuals into a productive problem-solving highly functioning team would be functioning in which stage of group development?
Correct Answer: D
Rationale: The performing stage is where a group functions at its highest level with effective problem-solving and productivity. Forming involves initial introductions where members are polite and cautious storming includes conflict as members assert roles and norming establishes cohesion and norms but these stages do not reflect the high functionality and problem-solving described in the question.
Question 5 of 5
On admission to the hospital the nurse notes that the client has a sacral wound that is yellow in color. What wound treatment would the nurse expect the health care provider to order?
Correct Answer: B
Rationale: A yellow wound indicates slough (nonviable tissue) requiring debridement to remove dead tissue and moist dressings to promote healing by maintaining a moist environment conducive to tissue regeneration. Oxygenation does not address slough barrier creams are for prevention and no treatment risks infection and delayed healing.