ATI RN
ATI Nursing 100 Day Exam 4 Fundamentals Questions
Extract:
Question 1 of 5
A postoperative client has an abdominal incision and a Penrose drain. Both are covered with an abdominal dressing. Which is an important nursing action associated with caring for a client with a Penrose drain?
Correct Answer: A
Rationale: Changing soiled dressings carefully prevents infection and ensures proper gravity drainage with a Penrose drain which lacks a reservoir or negative pressure system. Pinning the drain risks dislodgement and negative pressure or reservoir filling are not applicable to Penrose drains.
Question 2 of 5
The nurse recognizes that the application of heat therapy is appropriate for which client? The client who:
Correct Answer: C
Rationale: Heat therapy relaxes muscles and reduces pain in calf spasms by increasing blood flow and oxygen delivery promoting healing. It is contraindicated for bleeding (increases blood flow) impaired sensation (risks burns) and active inflammation (worsens swelling and infection risk).
Question 3 of 5
Which nursing action is most helpful in thinning a client's thick respiratory secretions?
Correct Answer: D
Rationale: Adequate fluid intake thins respiratory secretions by promoting hydration and mobilizing mucus reducing viscosity and aiding expectoration. Oxygen therapy supports oxygenation but not secretion thinning consistent air temperature has minimal impact and supine positioning may worsen secretion clearance by promoting stasis.
Question 4 of 5
The nurse recognizes that the most appropriate reason to suction a client is that:
Correct Answer: D
Rationale: Suctioning is indicated when the client cannot clear secretions effectively as evidenced by gurgling respirations and inability to cough ensuring airway patency. Routine suctioning every eight hours or hourly without clinical need is inappropriate as it may cause trauma or discomfort. Coughing and swallowing sputum indicates effective airway clearance not requiring suctioning.
Question 5 of 5
A client is recently diagnosed with pneumonia. The nurse observes the client sitting upright in the bed and assesses a respiratory rate of 26. The client states I can't catch my breath. Which abbreviation would be used to document this presentation?
Correct Answer: C
Rationale: SOB (shortness of breath) documents the client’s reported breathing difficulty and tachypnea aligning with pneumonia symptoms. R/O (rule out) is for tentative diagnoses S/P (status post) indicates past procedures and DOB (date of birth) is unrelated.