ATI RN
ATI Fundamentals Exam Nursing 100 Exam 3 Questions
Extract:
Question 1 of 5
The nurse is caring for a client with a wound from a biking accident. She assesses the wound and notices that the surrounding skin is very red and warm. The wound looks swollen and is draining a green like drainage. The nurse would recognize these symptoms would be a sign of what?
Correct Answer: B
Rationale: Redness warmth swelling and green drainage are indicative of infection caused by bacterial proliferation. Anemia affects blood wound healing shows granulation and necrosis involves dead tissue without these signs.
Question 2 of 5
When moving a client up in bed with the assistance of another caregiver,the nurse should:
Correct Answer: B
Rationale: Having the client fold their arms across the chest helps protect the arms and reduces the risk of injury during the move. It also stabilizes the client. Elevating the bed risks sliding consulting the plan of care is unrelated and a pillow is not necessary for moving.
Question 3 of 5
When measuring the size,depth,and wound tunneling of a client's stage 4 pressure injury what action should the nurse perform first?
Correct Answer: A
Rationale: Performing hand hygiene before wound care prevents infection and maintains aseptic technique preceding assessment or measurement steps.
Question 4 of 5
A client tells the nurse that he takes laxatives every day but is still constipated. The nurse's response is based on which reasoning?
Correct Answer: C
Rationale: Trying a laxative with a different mechanism may relieve constipation if the current one is ineffective. Enemas are not the first step habitual use is a factor but not the most common cause and chronic constipation requires attention.
Question 5 of 5
Upon assessment of a client's wound,the nurse notes the formation of granulation tissue. The tissue bleeds easily when the nurse performs wound care. What is the phase of wound healing characterized by the nurse's assessment?
Correct Answer: D
Rationale: Granulation tissue formation and easy bleeding are characteristic of the proliferation phase involving tissue repair. Hemostasis controls bleeding inflammation removes debris and maturation remodels collagen.