ATI RN
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ATI Nursing 100 Day Exam 4 Fundamentals Questions
Extract:
Question
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1 of 5
The nurse finds a client on bed rest experiencing clear signs of dyspnea. The nurse should assist the client to a:
Correct Answer: D
Rationale: Semi-Fowler’s position (head elevated 30-45 degrees) improves lung expansion and oxygenation in dyspnea by reducing diaphragm pressure. Trendelenberg worsens breathing by increasing abdominal pressure side-lying and supine may not optimize lung function.
Question 2 of 5
The nurse is caring for a client who is at high risk for development of pressure injury. The client is able to move independently but has been placed on bedrest. The client has experienced two episodes of urinary incontinence. Which intervention(s) should the nurse include in the care plan?
Correct Answer: A,D,E
Rationale: Shifting weight every 15 minutes reduces pressure on bony prominences moisture barrier cream protects against incontinence-related skin breakdown and a specialty mattress distributes pressure to prevent ulcers. Raising the bed at 45 degrees increases shear and massaging prominences risks tissue damage.
Question 3 of 5
The nurse must give a client an intramuscular injection of a medication which is very irritating to the subcutaneous tissues. To attempt to reduce irritation of the tissues which action should the nurse take?
Correct Answer: B
Rationale: The Z-track method prevents leakage of irritating medications into subcutaneous tissues by sealing the needle track reducing irritation and discomfort. Small gauge needles reduce pain not leakage 45-degree angles are for subcutaneous injections and ice does not prevent tissue irritation.
Question 4 of 5
A client is recently diagnosed with pneumonia. The nurse observes the client sitting upright in the bed and assesses a respiratory rate of 26. The client states I can't catch my breath. Which abbreviation would be used to document this presentation?
Correct Answer: C
Rationale: SOB (shortness of breath) documents the client’s reported breathing difficulty and tachypnea aligning with pneumonia symptoms. R/O (rule out) is for tentative diagnoses S/P (status post) indicates past procedures and DOB (date of birth) is unrelated.
Question 5 of 5
The nurse is aware that a common cause of under delegation in client care is:
Correct Answer: C
Rationale: Under-delegation often stems from a nurse’s need for perfectionism and control leading to reluctance to delegate tasks as they fear tasks won’t meet their standards. Over-delegation to assistive personnel is related to excessive delegation not under-delegation. A high degree of trust would facilitate delegation and nurses’ heavy workloads mean they often lack time to do all tasks themselves contradicting the idea of having time as a cause.