ATI RN
ATI Fundamentals Exam Special Unit ADN Questions
Extract:
Question 1 of 5
The nurse admitting an older patient notes a shallow open reddish, pink ulcer without slough on the right heel of the patient. How will the nurse stage this pressure ulcer?
Correct Answer: D
Rationale: Stage II: Stage II pressure ulcers involve partial-thickness skin loss with a shallow open wound, pink/red wound bed, and no slough. The given description matches Stage II. Stage IV: Stage IV ulcers involve full-thickness skin loss with exposed bone, tendon, or muscle. Since this ulcer is shallow and pink without slough, it is not Stage IV. Stage I: Stage I ulcers are intact skin with non-blanchable erythema. Since the ulcer is open, it is not Stage I. Stage III: Stage III ulcers have full-thickness tissue loss, possibly exposing subcutaneous fat. The given description lacks fat exposure or depth, ruling out Stage III.
Question 2 of 5
A nurse is caring for a patient with a wound. Which assessment data will be most relevant with regard to wound healing?
Correct Answer: D
Rationale: Pulse oximetry assessment: Oxygenation is a critical factor in wound healing. Low oxygen levels impair tissue repair, increase infection risk, and slow cell regeneration. Pulse oximetry assesses the oxygen levels in the blood, making it the most relevant assessment for wound healing. Muscular strength assessment: While muscular strength is important for overall mobility and health, it is not a key factor in wound healing. Wound healing is primarily influenced by oxygenation, perfusion, and nutrition. Sensation assessment: While sensation is important in patients with conditions like diabetes (due to the risk of neuropathy and unnoticed wounds), it is not the most relevant assessment for determining wound healing. Sleep assessment: Adequate rest is beneficial for healing, but sleep assessment is not the primary factor that determines wound healing. Other physiological factors play a greater role.
Question 3 of 5
The nurse is completing an assessment of the patient's skin integrity. Which assessment is the priority?
Correct Answer: A
Rationale: Pressure points: Pressure points (e.g., sacrum, heels, elbows, shoulders, hips) are at the highest risk for breakdown, ulcers, and impaired circulation. This makes them the priority assessment for skin integrity. Pulse points: While checking pulses is important for circulatory assessment, it is not directly related to skin integrity assessment. Breath sounds: Breath sounds assess respiratory function and are not a direct indicator of skin integrity. Bowel sounds: Bowel sounds assess gastrointestinal function and are not relevant in a skin integrity assessment.
Question 4 of 5
A nurse is teaching the patient with mitral valve problems about the valves of the heart. Starting on the right side of the heart, describe the sequence of blood flow through these valves. 1. Mitral; 2. Aortic; 3. Tricuspid; 4. Pulmonic
Correct Answer: C
Rationale: 3,4,1,2 (Tricuspid → Pulmonic → Mitral → Aortic): Blood flow through heart valves follows this order: Tricuspid Valve (Right atrium → Right ventricle), Pulmonic Valve (Right ventricle → Pulmonary artery → Lungs), Mitral Valve (Left atrium → Left ventricle), Aortic Valve (Left ventricle → Aorta → Body). 4,3,2,1 (Pulmonic → Tricuspid → Aortic → Mitral): This sequence incorrectly places the pulmonic valve first instead of the tricuspid. 1,3,2,4 (Mitral → Tricuspid → Aortic → Pulmonic): This sequence incorrectly starts with the mitral valve (left side of the heart), instead of the tricuspid (right side of the heart). 2,4,1,3 (Aortic → Pulmonic → Mitral → Tricuspid): This sequence incorrectly places the aortic valve first, which is incorrect for blood flow through the heart.
Question 5 of 5
A school nurse identifies that a child has pediculosis capitis and educates the child's parents about the condition. Which of the following statements by the parents indicates an understanding of the teaching?
Correct Answer: D
Rationale: All recently used clothing, bedding, and towels must be washed in hot water': Lice and nits can survive on fabric surfaces, so washing clothing, bedding, and towels in hot water (≥130°F/54°
C) and drying on high heat is recommended to eliminate them. 'I will treat all the family members to be on the safe side': Treatment is only recommended for individuals who have active lice or close, prolonged contact with the infected child. Treating everyone unnecessarily may lead to overuse of medications. 'My child must be free from nits before returning to school': The CDC and AAP do not recommend 'no-nit' policies, as nits alone do not indicate active infestation. Children can return to school after appropriate treatment begins. '
Toys that can't be dry cleaned or washed must be thrown out': Non-washable items should be sealed in a plastic bag for 2 weeks to kill lice, rather than being thrown away.