ATI RN
ATI Fundamentals Exam Special Unit ADN Questions
Extract:
Question 1 of 5
A nurse is caring for a patient with a wound. Which assessment data will be most relevant with regard to wound healing?
Correct Answer: D
Rationale: Pulse oximetry assessment: Oxygenation is a critical factor in wound healing. Low oxygen levels impair tissue repair, increase infection risk, and slow cell regeneration. Pulse oximetry assesses the oxygen levels in the blood, making it the most relevant assessment for wound healing. Muscular strength assessment: While muscular strength is important for overall mobility and health, it is not a key factor in wound healing. Wound healing is primarily influenced by oxygenation, perfusion, and nutrition. Sensation assessment: While sensation is important in patients with conditions like diabetes (due to the risk of neuropathy and unnoticed wounds), it is not the most relevant assessment for determining wound healing. Sleep assessment: Adequate rest is beneficial for healing, but sleep assessment is not the primary factor that determines wound healing. Other physiological factors play a greater role.
Question 2 of 5
A nurse on the telemetry(cardiac unit) is caring for a client who has unstable angina and is reporting chest pain with a severity of 6 on a 0-10 pain scale. The nurse administers 1 nitroglycerin (sublingual). After 5 minutes, the client states that his chest pain is now a severity of 2. Which of the following actions Should the nurse take?
Correct Answer: C
Rationale: Obtain an ECG/EKG: Even though the pain improved, unstable angina can progress to myocardial infarction. An ECG helps evaluate for ischemic changes and ensures the pain is truly resolving. Initiate a peripheral IV: While an IV line is useful for medication administration, the patient’s pain has significantly improved with nitroglycerin. An IV may be necessary later, but it is not the next step in this scenario. Administer another nitroglycerin tablet: Nitroglycerin can be repeated every 5 minutes up to 3 doses if chest pain persists or does not decrease significantly. Since the pain has improved (from 6 to 2), additional nitroglycerin is unnecessary. Call the Rapid Response Team (RRT): RRT should be called for worsening chest pain, unresponsiveness, or hemodynamic instability. Since the pain has improved, calling RRT is unnecessary.
Question 3 of 5
A nurse auscultates heart sounds. When the nurse hears S2, which valves is the nurse hearing close?
Correct Answer: D
Rationale: Aortic and Pulmonic: The second heart sound (S2) is produced by the closure of the aortic and pulmonic valves at the beginning of diastole. This marks the end of systole. Aortic and Mitral: The mitral valve is associated with the S1 sound, not S2. S2 occurs when the semilunar valves (aortic and pulmonic) close. Mitral and Pulmonic: The mitral valve closure is heard in S1, while the pulmonic valve closure is part of S2. However, the mitral valve is not involved in S2. Mitral and Tricuspid: The mitral and tricuspid valves close during S1, not S2. These valves are atrioventricular (AV) valves, not semilunar valves.
Question 4 of 5
The nurse is caring for a patient who has a wound drain with a collection device. The nurse notices that the collection device has a sudden decrease in drainage.
Correct Answer: A
Rationale: Call the health care provider, a blockage is present in the tubing: A sudden decrease in drainage can indicate a blockage in the tubing, which could lead to fluid buildup and infection. The provider should be notified so that interventions can be taken (e.g., irrigation, assessment for clot formation). Remove the drain, a drain is no longer needed: The nurse should not remove the drain without a provider’s order. A decrease in drainage does not necessarily mean the wound has healed. Do nothing as long as the evacuator is compressed: Even if the evacuator is compressed, a sudden decrease in drainage is abnormal and requires further investigation. Ignoring it can lead to complications like hematoma or infection. Chart the results on the intake and output flow sheet: While documenting the change is important, charting alone is not an appropriate intervention. The nurse must also assess for possible causes of the decreased drainage and notify the provider.
Question 5 of 5
A nurse auscultates heart sounds. When the nurse hears S2, which valves is the nurse hearing close?
Correct Answer: D
Rationale: Aortic and Pulmonic: The second heart sound (S2) is produced by the closure of the aortic and pulmonic valves at the beginning of diastole. This marks the end of systole. Aortic and Mitral: The mitral valve is associated with the S1 sound, not S2. S2 occurs when the semilunar valves (aortic and pulmonic) close. Mitral and Pulmonic: The mitral valve closure is heard in S1, while the pulmonic valve closure is part of S2. However, the mitral valve is not involved in S2. Mitral and Tricuspid: The mitral and tricuspid valves close during S1, not S2. These valves are atrioventricular (AV) valves, not semilunar valves.