ATI RN
ATI Fundamentals Exam Special Unit ADN Questions
Extract:
Question 1 of 5
A nurse teaches a patient about atelectasis. Which statement by the patient indicates an understanding of atelectasis?
Correct Answer: D
Rationale: It is important to do breathing exercises every hour to prevent atelectasis': Frequent deep breathing exercises, coughing, and incentive spirometry are essential for preventing atelectasis, especially after surgery. 'If I develop atelectasis, I will need a chest tube to drain excess fluid': Atelectasis is alveolar collapse, not fluid accumulation. Chest tubes are used for pneumothorax or pleural effusion, not for atelectasis. 'Hyperventilation will open up my alveoli, preventing atelectasis': Hyperventilation can cause respiratory alkalosis but does not effectively re-expand alveoli. Incentive spirometry and deep breathing are more effective. 'Atelectasis affects only those with chronic conditions such as emphysema': Atelectasis can affect anyone, especially postoperatively due to shallow breathing and reduced lung expansion. It is not exclusive to chronic conditions.
Question 2 of 5
The nurse is completing an assessment of the patient's skin integrity. Which assessment is the priority?
Correct Answer: A
Rationale: Pressure points: Pressure points (e.g., sacrum, heels, elbows, shoulders, hips) are at the highest risk for breakdown, ulcers, and impaired circulation. This makes them the priority assessment for skin integrity. Pulse points: While checking pulses is important for circulatory assessment, it is not directly related to skin integrity assessment. Breath sounds: Breath sounds assess respiratory function and are not a direct indicator of skin integrity. Bowel sounds: Bowel sounds assess gastrointestinal function and are not relevant in a skin integrity assessment.
Question 3 of 5
The wound care nurse is monitoring a patient with a stage III pressure ulcer whose wound presents with healthy tissue. How should the nurse document this in the patient's medical record?
Correct Answer: C
Rationale: Healing Stage III Pressure Ulcer: Pressure ulcers are documented at their worst stage, even as they heal. The correct terminology includes 'healing' to show improvement. Stage I Pressure Ulcer: A Stage III pressure ulcer does not regress to a Stage I as it heals. It retains its original staging classification. Stage III Pressure Ulcer: While the ulcer was originally Stage III, documenting it this way without specifying healing progress does not accurately reflect its current condition. Healing Stage II Pressure Ulcer: A Stage III ulcer does not become a Stage II ulcer as it heals; instead, it is called a healing Stage III pressure ulcer.
Question 4 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 5 of 5
Which finding will alert the nurse to a potential wound dehiscence?
Correct Answer: A
Rationale: Report by patient that something has given way: A patient reporting a 'giving way' sensation is a classic early sign of dehiscence, indicating that the wound edges are separating. Drainage that is odorous and purulent: Purulent (pus-like) and foul-smelling drainage suggests infection, not necessarily dehiscence. Infection can contribute to dehiscence, but it is not the defining feature. Protrusion of visceral organs through a wound opening: Evisceration occurs when internal organs protrude through the incision. Dehiscence is partial or complete separation of the wound edges without organ protrusion. Chronic drainage of fluid through the incision site: Persistent drainage suggests a fistula (abnormal connection between tissues), infection, or poor wound healing, rather than wound dehiscence.