ATI RN
ATI Nurs 100 Fundamentals Quiz Questions
Extract:
Question 1 of 5
A nurse is assessing a client who has urinary retention. Which of the following findings should the nurse expect?
Correct Answer: C
Rationale: Leakage of urine (overflow incontinence) occurs when the bladder is overly full due to retention.
Question 2 of 5
A nurse is assessing a client who has urinary retention. Which of the following findings should the nurse expect?
Correct Answer: C
Rationale: Leakage of urine (overflow incontinence) occurs when the bladder is overly full due to retention.
Question 3 of 5
A nurse is developing a plan of care to prevent skin breakdown for a client with a spinal cord injury and paralysis. Which of the following nursing actions are appropriate? (Select all that apply.)
Correct Answer: D,E
Rationale: Using pillows to keep heels off the bed and minimizing moisture exposure prevent pressure ulcers and skin breakdown.
Extract:
Medical History
Type 2 diabetes mellitus
Obesity (BMI 32)
Peripheral vascular disease (PVD)
Heart failure
Hypertension
Nurses Notes
0800:
Client awake, alert, and oriented x 3. Moves all extremities to command. Febrile.
Normal sinus rhythm. Bilateral pedal pulses +1 bilaterally.
Respirations unlabored. Oxygen at 2L via nasal cannula in use. Crackles heard bilaterally upon auscultation. Reminded client to turn, cough, and deep breathe; and importance of splinting abdomen when coughing to protect surgical incision. Client verbalized understanding.
Bowel sounds x 4 quadrants active. Reports bowel movement yesterday. Tolerating regular diet with no nausea/vomiting
States voiding without difficulty, clear yellow urine. Voided 750 mL over last 8 hr.
Dressing to incision intact with serosanguinous drainage noted and marked.
1000:
Client out of bed to chair with the assist of 1. Medicated with hydromorphone 1 tablet PO prior to abdominal dressing change.
1100:
Client up walking in room, assisted back to bed. Abdominal dressing changed. Incision with top edges slightly separated; lower edges approximated. Lower staples intact, upper staples appear stretched out. incision with redness and purulent drainage present.
Question 4 of 5
A nurse is caring for a client who had abdominal surgery 3 days ago. Select words from the choices below to fill in each blank in the following sentence. The client is at risk for developing ------------------ and--------------------- and -------------------
Correct Answer: A,B,C
Rationale: Obesity, diabetes, and surgical history increase wound infection risk; incision separation risks dehiscence; and reduced mobility risks pneumonia.
Extract:
Question 5 of 5
A nurse is caring for a client who is postoperative following abdominal surgery. Which of the following findings should indicate to the nurse the client's peristalsis is returning?
Correct Answer: C
Rationale: Passage of flatus indicates returning peristalsis as the intestines resume moving contents.