ATI RN
ATI Fundamentals Exam Nursing 100 Exam 3 Questions
Extract:
Question 1 of 5
A nurse is assessing a client who has a wound that is healing by first intention. Which of the following findings should the nurse expect?
Correct Answer: A
Rationale: Wound healing by first intention involves the approximation of wound edges often closed with sutures resulting in minimal scarring. Contamination granulation tissue and prolonged healing are characteristic of second intention healing.
Question 2 of 5
A nurse working in long-term care facility is assessing residents at risk for the development of a pressure injury. Which resident would be most at risk?
Correct Answer: A
Rationale: The client who is 92 years old uses a walker is incontinent and has an extensive cardiac history is at higher risk for the development of pressure injuries due to age immobility and additional risk factors like incontinence and poor circulation from cardiac issues. Paraplegia and coma increase risk but the combination of factors in choice A is more severe. The client with a cane and dementia has fewer risk factors.
Question 3 of 5
A nurse assessing a client notes that the client has a constant leakage of small amounts of urine and a bladder that is distended and palpable. The nurse should associate these findings with which of the following types of urinary incontinence?
Correct Answer: A
Rationale: Overflow incontinence involves constant leakage and a distended bladder due to incomplete emptying. Reflex is neurologic stress occurs with pressure and urge involves sudden voiding.
Question 4 of 5
When measuring the size,depth,and wound tunneling of a client's stage 4 pressure injury what action should the nurse perform first?
Correct Answer: A
Rationale: Performing hand hygiene before wound care prevents infection and maintains aseptic technique preceding assessment or measurement steps.
Question 5 of 5
A nurse is assisting a client during ambulation when the client begins to fall. Which of the following actions should the nurse take?
Correct Answer: C
Rationale: Lowering the client to the floor reduces fall distance and injury risk. Leaning toward the wall narrow stance or arm support are insufficient to prevent injury during a fall.