ATI RN
ATI Nursing 100 Day Exam 4 Fundamentals Questions
Extract:
Question 1 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 2 of 5
It is most critical for the nurse to use a filtered needle when preparing a parenteral medication that:
Correct Answer: A
Rationale: A filtered needle prevents glass particles from an ampule (broken to access medication) entering the syringe reducing risks of tissue damage or embolism. Mixing medications reconstitution or clear solutions do not inherently produce particles requiring filtration.
Question 3 of 5
In order to minimize discomfort when giving an injection to a client the nurse should:
Correct Answer: A
Rationale: Spreading the skin taut reduces discomfort by minimizing needle puncture sensation and stabilizing the tissue for smoother insertion. Applying heat is not standard holding the syringe still ensures accuracy not comfort and blood return checks are for specific injections not pain reduction.
Question 4 of 5
A postoperative client has an abdominal incision and a Penrose drain. Both are covered with an abdominal dressing. Which is an important nursing action associated with caring for a client with a Penrose drain?
Correct Answer: A
Rationale: Changing soiled dressings carefully prevents infection and ensures proper gravity drainage with a Penrose drain which lacks a reservoir or negative pressure system. Pinning the drain risks dislodgement and negative pressure or reservoir filling are not applicable to Penrose drains.
Question 5 of 5
The nurse notes that a diuretic is listed on the client's medication administration record (MAR). It is most important for the nurse to report to the physician a serum:
Correct Answer: B
Rationale: A low potassium level (3.2 mEq/L below normal 3.5-5.0 mEq/L) indicates hypokalemia a serious diuretic side effect risking arrhythmias and requiring immediate reporting. Normal sodium (135-145 mEq/L) hematocrit (38-50%) and chloride (95-105 mEq/L) levels are less urgent.