ATI RN
RN ATI Fundamentals of Nursing Questions
Extract:
A nurse is caring for a client.
Nurses' Notes
Day 1:
1300:
Client has a 2.5 cm (1 in) x 2.5 cm (1 in) stage 2 pressure injury to dorsal lateral aspect of left heal; wound bed red, moist, approximated edges; surrounding skin inflamed, red,, non-tender to palpation. Client reports pain score of 0 on 0 to 10 pain scale. Pedal pulse left foot 1+, unable to assess capillary refill due to toe fungus bilaterally, Pedal pulse right foot 2+. Wound care as prescribed; heel floated on pillow.
Medical History
Day 1:
Diabetes mellitus Hyperlipidemia
Labs
Day 1
Hct 38% (37% to 47%)
Hgb 13 (12 g/dL to 16 g/dL)
WBC 11,500/mm3 (5000 to 10,000/mm3)
Potassium 3.6 mEq/L (3.5 mEq/L to 5 mEq/L)
Pre-albumin level 10 mg/dL (15 to 36 mg/dL)
Albumin: 3.0 g/dL (3.5 to 5 g/dL)
Fingerstick blood glucose, fasting 186 mg/dL (74 to 106 mg/dL)
Question 1 of 5
Select the 5 findings that can cause delayed wound healing.
Correct Answer: B,C,D,E,F
Rationale: Low prealbumin (
B) diabetes (
C) hyperlipidemia (
D) wound infection (E) and decreased perfusion (F) impair healing by affecting nutrition blood flow and immune response.
Choices A and G are not direct causes.
Extract:
Question 2 of 5
A nurse is providing discharge teaching for a client who requires home oxygen therapy. Which of the following statements should the nurse identify as an indication that the client needs further teaching?
Correct Answer: A
Rationale: Synthetic clothing and woolen socks (
A) can generate static electricity a fire hazard with oxygen. Other statements are correct.
Question 3 of 5
A nurse is caring for a client who has impaired mobility. Which of the following support devices should the nurse plan to use to prevent the client from developing plantar flexion contractures?
Correct Answer: B
Rationale: A footboard maintains feet in a dorsiflexed position preventing plantar flexion contractures.
Choice A prevents pressure ulcers
Choice C addresses hip rotation and
Choice D maintains hip alignment.
Question 4 of 5
A nurse is providing hygiene care for a client who is immobile. Which of the following actions should the nurse take?
Correct Answer: B,C,E
Rationale: Checking items (
B) shaving correctly (
C) and maintaining proper water temperature (E) ensure safety and comfort.
Choices A and D are incorrect techniques.
Question 5 of 5
A nurse is receiving a provider's prescription for a client via telephone. Which of the following actions should the nurse take to ensure the accuracy of the telephone prescription? (Select all that apply.)
Correct Answer: B,C,E
Rationale: Questioning unclear orders (
B) transcribing accurately (
C) and repeating back (E) ensure prescription accuracy.
Choices A and D are incorrect or incomplete.