ATI RN
ATI Nursing 100 Day Exam 4 Fundamentals Questions
Extract:
Question 1 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 2 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 3 of 5
The nurse is caring for a client who has been wearing a nitroglycerin patch and receives an order to start a nitroglycerin intravenous Infusion. The old patch must be removed from the client's body in order to avoid:
Correct Answer: C
Rationale: Removing the nitroglycerin patch prevents overdose as both patch and IV infusion deliver the drug systemically risking excessive vasodilation and hypotension. Skin irritation is a side effect interactions are not primary and patch loss is irrelevant when switching routes.
Question 4 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).
Question 5 of 5
A one-day post-operative client complains of severe abdominal pain and has shallow respirations at 22/minute. The client is reluctant to perform coughing and deep breathing. Based on the data the priority problem that the nurse could assign to this patient is:
Correct Answer: B
Rationale: Shallow respirations and reluctance to cough indicate an ineffective breathing pattern risking atelectasis and pneumonia due to pain limiting deep breathing. Ineffective gas exchange may result but is secondary activity intolerance is less urgent and no data supports decreased cardiac function.