ATI RN
ATI RN Fundamental Proctored Exam With NGN Graded Questions
Extract:
Question 1 of 4
An adolescent who has diabetes mellitus is 2 days postop following an appendectomy. The client is tolerating a regular diet. He has ambulated successfully around the unit with assistance. He requests pain meds Q 6-8 hr while reporting pain at a 2 on a scale of 1-10 after receiving the med. His incision is approximated & free of redness, with scant serous drainage on the dressing. Which of the following risk factors for poor wound healing does this client have? Select all.
Correct Answer: B, C
Rationale: The correct answers are B (Impaired circulation) and C (Impaired/suppressed immune system). Impaired circulation can lead to decreased oxygen and nutrient delivery to the wound site, hindering the healing process. In this case, the adolescent may have impaired circulation due to diabetes mellitus. An impaired/suppressed immune system can also delay wound healing by impairing the body's ability to fight off infection and promote tissue repair. The other options are not applicable in this scenario: A (Extremes in age) does not apply as the client is an adolescent; D (Malnutrition) is not indicated as the client is tolerating a regular diet; and E (Poor wound care) is not evident as the incision is well-approximated and free of redness, with only scant serous drainage.
Question 2 of 4
A nurse is assessing a client who is 5 days postop following abdominal surgery. The surgeon suspects an incisional wound infection and has prescribed antibiotic therapy for the nurse to initiate after collecting wound & blood specimens for culture & sensitivity. Which of the following assessment findings should the nurse expect? Select all.
Correct Answer: A, B, C
Rationale: The correct assessment findings the nurse should expect in a client suspected of having an incisional wound infection include:
A) Increase in incisional pain: Infection can cause localized pain.
B) Fever & chills: Systemic signs of infection.
C) Reddened wound edges: Classic sign of wound infection. Incorrect choices:
D) Increase in serosanguineous drainage: This is more indicative of normal wound healing. E) Decrease in thirst: Unrelated to wound infection. Overall, pain, fever, and redness are key signs of infection that the nurse should look out for.
Question 3 of 4
A nursing instructor is reviewing the wound healing process with a group of nursing students. They should be able to identify which of the following alterations as a wound or injury that heals by secondary intention? Select all.
Correct Answer: A, E
Rationale: The correct answers are A and E because wounds healing by secondary intention involve tissue loss and heal from the bottom up with granulation tissue filling in the wound. A Stage III pressure ulcer and an open burn area are examples of wounds that heal by secondary intention due to tissue loss.
Choices B and D are incorrect because sutured surgical incisions and lacerations sealed with adhesive heal by primary intention, where wound edges are approximated and heal with minimal scarring.
Choice C, a casted bone fracture, is incorrect as fractures heal through a different process involving the formation of callus and subsequent bone remodeling, not by secondary intention healing.
Question 4 of 4
A client who had abdominal surgery 24 hr ago reports a pulling sensation & pain in his surgical incision. The nurse checks the client's surgical wound and finds the wound separated with viscera protruding. Which of the following interventions is appropriate? Select all.
Correct Answer: A, D
Rationale:
Correct
Answer: A, D
Rationale:
1. Covering the area with saline-soaked sterile dressings (
Choice
A) helps to protect the exposed tissues, prevent infection, and maintain a moist environment for healing.
2. Positioning the client supine with hips and knees bent (
Choice
D) can help reduce tension on the wound, alleviate pain, and minimize the risk of further tissue damage.
Summary:
- Applying an abdominal binder (
Choice
B) may increase pressure on the wound, exacerbating the situation.
- Using sterile gloves to apply pressure to exposed tissues (
Choice
C) can introduce contamination and should be avoided.
- Offering a warm beverage (
Choice E) is irrelevant and does not address the urgent need to manage the wound.
Question 5 of 4
A nurse is caring for an older adult client who is at risk for developing pressure ulcers. Which of the following interventions should the nurse use to help maintain the integrity of the client's skin? Select all.
Correct Answer: A, D
Rationale: The correct interventions (A and
D) are crucial for preventing pressure ulcers in older adults. Elevating the head of the bed at 30 degrees helps reduce pressure on the sacrum and heels, key areas prone to pressure ulcers. Sitting on a gel cushion distributes pressure evenly, reducing the risk of skin breakdown.
Incorrect
Choices:
B: Massaging bony prominences can increase friction and shear forces, leading to skin breakdown.
C: Cornstarch can create a moist environment, increasing the risk of maceration and skin breakdown.
E: Repositioning every 3 hours is insufficient for preventing pressure ulcers, as more frequent repositioning is needed to reduce prolonged pressure on the skin.