ATI RN
ATI Nursing 100 Day Exam 4 Fundamentals Questions
Extract:
Question 1 of 5
On admission to the hospital the nurse notes that the client has a sacral wound that is yellow in color. What wound treatment would the nurse expect the health care provider to order?
Correct Answer: B
Rationale: A yellow wound indicates slough (nonviable tissue) requiring debridement to remove dead tissue and moist dressings to promote healing by maintaining a moist environment conducive to tissue regeneration. Oxygenation does not address slough barrier creams are for prevention and no treatment risks infection and delayed healing.
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
An adult client is to receive ear drops four times a day to treat an inner ear infection. What is the correct nursing procedure to follow when administering this type of medication?
Correct Answer: C
Rationale: Pulling the auricle up and back straightens the ear canal in adults for effective ear drop administration ensuring medication reaches the inner ear. Down and back is for children pulling the earlobe post-instillation is unnecessary and microwaving risks burns.
Question 4 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 5 of 5
The client has an open wound on the sacrum with an order for the following: Apply hydrogel dressing on the wound. Change dressing every day. The nurse recognizes that the primary purpose of this dressing is to:
Correct Answer: B
Rationale: Hydrogel dressings provide a moist environment to promote healing by facilitating autolytic debridement and granulation tissue formation. They do not primarily protect from pressure (handled by devices) enhance primary intention (for surgical wounds) or absorb drainage (hydrocolloids do this).