ATI RN
ATI Nursing 100 Day Exam 4 Fundamentals Questions
Extract:
Question 1 of 5
The nurse enters a client's room to find that his abdominal wound has eviscerated. Which intervention should the nurse implement first?
Correct Answer: D
Rationale: Applying a sterile saline dressing protects eviscerated abdominal contents by keeping them moist and preventing infection until surgical intervention. Reverse Trendelenburg may increase protrusion antibiotics are secondary and replacing organs risks damage and is not a nursing action.
Question 2 of 5
The nurse recognizes that the most appropriate reason to suction a client is that:
Correct Answer: D
Rationale: Suctioning is indicated when the client cannot clear secretions effectively as evidenced by gurgling respirations and inability to cough ensuring airway patency. Routine suctioning every eight hours or hourly without clinical need is inappropriate as it may cause trauma or discomfort. Coughing and swallowing sputum indicates effective airway clearance not requiring suctioning.
Question 3 of 5
The best way for the nurse to assess a client's level of dyspnea is to:
Correct Answer: B
Rationale: Observing dyspnea at rest and during activity provides a comprehensive assessment of respiratory distress by noting changes in breathing patterns effort and symptoms. Documentation offers historical data subjective reports may be unreliable and lung sounds assess lung function not dyspnea severity directly.
Question 4 of 5
The nurse receives the following order: Ferrous sulfate 325 mg four times a day PO. Give on empty stomach. Even before researching the nurse guesses that this is because the medication:
Correct Answer: A
Rationale: Ferrous sulfate is better absorbed on an empty stomach as food especially dairy or fiber can form complexes reducing bioavailability. Gastric acid enhances absorption constipation is a side effect not related to timing and while irritation can occur the primary reason is absorption optimization.
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).