ATI RN
RN ATI Fundamentals of Nursing Questions
Extract:
Question 1 of 5
A nurse is planning care for a client who has a decreased level of consciousness. The client is receiving continuous enteral feedings via a gastrostomy tube due to an inability to swallow. Which of the following is the priority action by the nurse?
Correct Answer: C
Rationale: Elevating the head of the bed 30° to 45° is the priority to prevent aspiration a significant risk in clients with decreased consciousness.
Choices A B and D are important but secondary.
Question 2 of 5
A nurse is caring for a client who has a wound infection. Which of the following actions should the nurse take when obtaining a wound-drainage specimen for culture?
Correct Answer: D
Rationale: Cleansing with 0.9% sodium chloride saline removes debris ensuring an accurate culture from the wound site.
Choice A may interfere with results
Choice B contaminates the sample and
Choice C is irrelevant for wound culture.
Question 3 of 5
A nurse is planning care for an older adult client who is at risk for developing pressure ulcers. Which of the following interventions should the nurse use to help maintain the integrity of the client's skin?
Correct Answer: A
Rationale: Elevating the head no more than 45° (
A) reduces pressure on the sacrum preventing ulcers. Other choices increase risk or are ineffective.
Question 4 of 5
A nurse is reviewing information about the Health Insurance Portability and Accountability Act (HIPAA) with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates a need for further teaching?
Correct Answer: A
Rationale: HIPAA restricts sharing client information with family without consent or specific conditions making
Choice A incorrect.
Choices B,C and D are accurate statements about HIPAA.
Extract:
A nurse is caring for a client.
Nurses' Notes
Day 1:
1300:
Client has a 2.5 cm (1 in) x 2.5 cm (1 in) stage 2 pressure injury to dorsal lateral aspect of left heal; wound bed red, moist, approximated edges; surrounding skin inflamed, red,, non-tender to palpation. Client reports pain score of 0 on 0 to 10 pain scale. Pedal pulse left foot 1+, unable to assess capillary refill due to toe fungus bilaterally, Pedal pulse right foot 2+. Wound care as prescribed; heel floated on pillow.
Medical History
Day 1:
Diabetes mellitus Hyperlipidemia
Labs
Day 1
Hct 38% (37% to 47%)
Hgb 13 (12 g/dL to 16 g/dL)
WBC 11,500/mm3 (5000 to 10,000/mm3)
Potassium 3.6 mEq/L (3.5 mEq/L to 5 mEq/L)
Pre-albumin level 10 mg/dL (15 to 36 mg/dL)
Albumin: 3.0 g/dL (3.5 to 5 g/dL)
Fingerstick blood glucose, fasting 186 mg/dL (74 to 106 mg/dL)
Question 5 of 5
Select the 5 findings that can cause delayed wound healing.
Correct Answer: B,C,D,E,F
Rationale: Low prealbumin (
B) diabetes (
C) hyperlipidemia (
D) wound infection (E) and decreased perfusion (F) impair healing by affecting nutrition blood flow and immune response.
Choices A and G are not direct causes.