ATI RN
ATI Nursing 100 Day Exam 4 Fundamentals Questions
Extract:
Question 1 of 5
A one-day post-operative client complains of severe abdominal pain and has shallow respirations at 22/minute. The client is reluctant to perform coughing and deep breathing. Based on the data the priority problem that the nurse could assign to this patient is:
Correct Answer: B
Rationale: Shallow respirations and reluctance to cough indicate an ineffective breathing pattern risking atelectasis and pneumonia due to pain limiting deep breathing. Ineffective gas exchange may result but is secondary activity intolerance is less urgent and no data supports decreased cardiac function.
Question 2 of 5
An alert competent client refuses to take her antihypertensive medication. The nurse has explained why the medication is important and the client states that she understands but doesn't want to take the medication. What is the best nursing action?
Correct Answer: B
Rationale: Respecting the client’s autonomy the nurse withholds the medication and notifies the prescriber for further action as the client understands but refuses. Administering against wishes violates ethics filing a report is unnecessary and insisting without prescriber input disregards autonomy.
Question 3 of 5
When doing the client's skin assessment the nurse notes a 3 cm area of partial thickness skin loss that looks like a blister on the client's sacral area. The nurse consults the wound care nurse who stages the wound as a pressure ulcer.
Correct Answer: B
Rationale: Partial thickness skin loss appearing as a blister indicates a Stage II pressure ulcer involving the epidermis and dermis. Stage I is intact skin with redness Stage III involves full-thickness loss and Stage IV includes deep tissue damage like muscle or bone.
Question 4 of 5
The nurse is assessing a client who exhibits positive Trousseau's and Chvostek's signs. What laboratory value would validate these clinical findings? A serum:
Correct Answer: D
Rationale: Low calcium (6.9 mg/dL below normal 8.5-10.2 mg/dL) causes neuromuscular excitability leading to Trousseau’s (arm spasm with cuff inflation) and Chvostek’s (facial twitching) signs. Normal potassium (3.5-5.0 mEq/L) phosphate (2.5-4.5 mg/dL) and magnesium (1.8-2.5 mEq/L) do not explain these findings.
Question 5 of 5
The client has had a surgical debridement of a wound which is starting to heal. In order to further promote healing this client should be encouraged to consume a balanced diet with emphasis on increased:
Correct Answer: B
Rationale: Vitamin C is essential for collagen synthesis and wound healing as it supports tissue repair and immune function. Carbohydrates provide energy but are not specific to healing calcium aids bone health and vitamin E’s antioxidant role is less critical for wounds.