ATI RN
ATI Nursing 100 Day Exam 4 Fundamentals Questions
Extract:
Question 1 of 5
The nurse has applied a topical agent to the client's skin and then applies an ice pack to the area. This is done to:
Correct Answer: B
Rationale: An ice pack slows topical drug absorption by causing vasoconstriction which reduces blood flow to the area allowing prolonged local action of the medication. It is not primarily used for comfort as cooling may not always reduce discomfort. Drug excretion is not affected by topical ice and maximizing distribution would require increased blood flow not reduction.
Question 2 of 5
The nurse is assessing a client who exhibits positive Trousseau's and Chvostek's signs. What laboratory value would validate these clinical findings? A serum:
Correct Answer: D
Rationale: Low calcium (6.9 mg/dL below normal 8.5-10.2 mg/dL) causes neuromuscular excitability leading to Trousseau’s (arm spasm with cuff inflation) and Chvostek’s (facial twitching) signs. Normal potassium (3.5-5.0 mEq/L) phosphate (2.5-4.5 mg/dL) and magnesium (1.8-2.5 mEq/L) do not explain these findings.
Question 3 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 4 of 5
The nurse understands that the major factor affecting oxygenation in a client who has fluid in the lungs is:
Correct Answer: B
Rationale: Fluid in the lungs (e.g. pulmonary edema) impairs oxygen diffusion across the alveolar membrane reducing oxygenation as fluid blocks gas exchange. Poor perfusion lowered hemoglobin or reduced ambient oxygen are secondary or unrelated to lung fluid’s direct effect on diffusion.
Question 5 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.