ATI RN
ATI Fundamentals Exam Nursing 100 Exam 3 Questions
Extract:
Question 1 of 5
A nurse working in an emergency room is assessing a client who has a leg wound. The nurse notes a full-thickness wound with jagged edges and muscle tissue visible after a biking accident. The nurse should document this as which of the following types of wounds?
Correct Answer: D
Rationale: The correct answer is D: Unintentional open wound. This wound is unintentional as it resulted from a biking accident. It is an open wound as the skin is broken, exposing muscle tissue. The jagged edges and visibility of muscle tissue indicate significant tissue damage, typical of an open wound. A: Unintentional closed wound is incorrect because the wound is open. B: Intentional closed wound is incorrect as the wound was not purposely created. C: Intentional open wound is incorrect as the wound was not deliberately made open.
Question 2 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: The correct answer is A: Overflow incontinence. This type of urinary incontinence is characterized by a constant leakage of small amounts of urine due to an overfull bladder that is distended and palpable. The bladder becomes unable to empty completely, leading to the constant dribbling of urine. This can be caused by conditions such as bladder outlet obstruction or weak bladder contractions.
Summary of other choices:
B: Reflex incontinence - Involuntary loss of urine due to a lack of control over the bladder's reflex activity. Not associated with a distended bladder.
C: Stress incontinence - Involuntary leakage of urine during activities that increase intra-abdominal pressure, such as coughing or sneezing. Not associated with a distended bladder.
D: Urge incontinence - Involuntary loss of urine associated with a sudden, strong urge to urinate. Not associated with a distended bladder.
Question 3 of 5
A nurse is caring for a client who has a prescription for a stool test for occult. The nurse understands the purpose of the test is to check the stool for which of the following substances?
Correct Answer: D
Rationale: The correct answer is D: Blood. A stool test for occult blood is performed to detect hidden blood in the feces, which may indicate gastrointestinal bleeding. This test is important for screening and diagnosing various conditions such as gastrointestinal ulcers, inflammatory bowel disease, or colorectal cancer. Checking for bacteria (choice
A), parasites (choice
B), or steatorrhea (choice
C) would require different tests and are not the purpose of a stool occult blood test. Blood in the stool can be a significant indicator of underlying health issues, making it the correct substance to check for in this scenario.
Question 4 of 5
The nurse uses gait belts when assisting clients to ambulate. Which client would be a likely candidate for this assistive device?
Correct Answer: B
Rationale: The correct answer is B. A client with leg strength who can cooperate with movement is a likely candidate for a gait belt as they can actively participate in walking. Clients confined to bedrest (
A) cannot ambulate, clients with thoracic (
C) or abdominal (
D) incisions may have restrictions on movement due to surgical sites. Other choices do not provide enough information to determine candidacy for a gait belt.
Question 5 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 correct answer is A. The resident who is 92 years old, uses a walker, is incontinent, and has an extensive cardiac history is at the highest risk for developing a pressure injury. Age, immobility (use of walker), incontinence, and medical conditions like cardiac history are all significant risk factors for pressure injuries. The combination of these factors increases the vulnerability of the skin to damage from pressure, leading to the development of pressure injuries.
Choice B is less likely as age is a major risk factor.
Choice C, a comatose client, may have reduced mobility but the other factors in choice A pose a higher risk.
Choice D, a client with dementia, may have mobility issues but the other factors in choice A still present a higher risk.