ATI RN
ATI Fundamentals Final Exam Questions
Extract:
Question 1 of 5
The client has a documented stage II pressure ulcer on the right hip. What NANDA nursing diagnosis problem statement is most appropriate to use with this client?
Correct Answer: D
Rationale: A stage II pressure ulcer is a wound that involves partial-thickness loss of skin. The most appropriate NANDA nursing diagnosis problem statement for a client with this condition would be Impaired Skin Integrity as it specifically reflects the damage to the skin's surface. Impaired Tissue Integrity is less specific as it could apply to deeper tissue damage while the other options are not directly relevant to the condition described.
Question 2 of 5
A nurse is caring for an older adult client who is at risk for skin breakdown. The nurse should use which of the following interventions to help maintain the integrity of the client's skin?
Correct Answer: C
Rationale: A diet high in protein supports tissue repair and wound healing helping maintain skin integrity in older adults. Repositioning every 3 hours may be insufficient cornstarch can irritate skin and massaging bony prominences may damage fragile skin.
Question 3 of 5
A client has a history of an inconsistent fecal elimination pattern. What should the nurse instruct this client to improve this health problem?
Correct Answer: A,B
Rationale: The nurse should instruct the client to include more whole grains in their diet and increase water intake to improve an inconsistent fecal elimination pattern. Whole grains are high in fiber which adds bulk to stool and promotes regular bowel movements. Adequate hydration ideally 8–10 glasses of water daily keeps stools soft and easier to pass. While option B suggests 2–4 glasses increasing water intake is still beneficial though the amount is suboptimal. Spicy foods and sugar (
C) may irritate the bowel and enemas (
D) are not a long-term solution and may disrupt normal bowel function.
Question 4 of 5
The nurse is identifying outcomes for a client with the nursing diagnosis of Stress Urinary Incontinence. Which outcome would be related to sphincter incompetence?
Correct Answer: A
Rationale: Stress urinary incontinence is the involuntary loss of urine during physical activity such as coughing sneezing or exercising often caused by weakness of the pelvic floor muscles and/or the urethral sphincter. An appropriate outcome for a client with this condition would be to improve the strength of these muscles. Performing isometric squeezes also known as Kegel exercises can help strengthen the pelvic floor muscles and improve sphincter competence directly addressing the issue of sphincter incompetence and reducing episodes of incontinence.
Question 5 of 5
A nurse mistakenly gave a client who was NPO a morning breakfast tray. After realizing the mistake
Correct Answer: D
Rationale: In this situation the nurse demonstrated integrity. After realizing the mistake of giving a client who was NPO a morning breakfast tray the nurse took responsibility for the error by notifying the physician and the client explaining the consequences (such as a delay in the scheduled procedure) and documenting the situation in the client's medical record. Integrity involves honesty accountability and adherence to ethical standards which the nurse exemplified through these actions. Altruism refers to selfless concern for others human dignity involves respecting the client's worth and social justice pertains to fairness in care distribution none of which are as directly related to this scenario as integrity.