ATI RN
ATI Fundamentals Exam Nursing 100 Exam 3 Questions
Extract:
Question 1 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 client who is 92 years old uses a walker is incontinent and has an extensive cardiac history is at higher risk for the development of pressure injuries due to age immobility and additional risk factors like incontinence and poor circulation from cardiac issues. Paraplegia and coma increase risk but the combination of factors in choice A is more severe. The client with a cane and dementia has fewer risk factors.
Question 2 of 5
When measuring the size,depth,and wound tunneling of a client's stage 4 pressure injury what action should the nurse perform first?
Correct Answer: A
Rationale: Performing hand hygiene before wound care prevents infection and maintains aseptic technique preceding assessment or measurement steps.
Question 3 of 5
A nurse is assessing a client who has a wound that is healing by first intention. Which of the following findings should the nurse expect?
Correct Answer: A
Rationale: Wound healing by first intention involves the approximation of wound edges often closed with sutures resulting in minimal scarring. Contamination granulation tissue and prolonged healing are characteristic of second intention healing.
Question 4 of 5
Reflex incontinence is associated with neurologic dysfunction and occurs when no warning or stress precedes periodic involuntary urination.
Correct Answer: D
Rationale: Reflex incontinence is associated with neurologic dysfunction such as spinal cord injury causing involuntary urination without warning aligning with the description. Stress transient and total incontinence have different causes and characteristics.
Question 5 of 5
A nurse is assessing a client who is experiencing complications due to immobility. Which of the following findings should the nurse expect? (Select All that Apply.)
Correct Answer: A,D,E
Rationale: Contractures atelectasis and pressure ulcers are complications of immobility due to muscle shortening reduced lung expansion and prolonged pressure. Diarrhea and polyuria are not typically related.