ATI RN
ATI Fundamentals Exam Special Unit ADN Questions
Extract:
Question 1 of 5
The nurse is caring for a patient who has a wound drain with a collection device. The nurse notices that the collection device has a sudden decrease in drainage.
Correct Answer: A
Rationale: Call the health care provider, a blockage is present in the tubing: A sudden decrease in drainage can indicate a blockage in the tubing, which could lead to fluid buildup and infection. The provider should be notified so that interventions can be taken (e.g., irrigation, assessment for clot formation). Remove the drain, a drain is no longer needed: The nurse should not remove the drain without a provider’s order. A decrease in drainage does not necessarily mean the wound has healed. Do nothing as long as the evacuator is compressed: Even if the evacuator is compressed, a sudden decrease in drainage is abnormal and requires further investigation. Ignoring it can lead to complications like hematoma or infection. Chart the results on the intake and output flow sheet: While documenting the change is important, charting alone is not an appropriate intervention. The nurse must also assess for possible causes of the decreased drainage and notify the provider.
Question 2 of 5
Which patient scenario of a surgical patient in pain is most indicative of critical thinking?
Correct Answer: B
Rationale: Asking the patient what pain-relief methods, pharmacological and nonpharmacological, have worked best in the past: This approach assesses the patient’s individual experience and applies personalized care, which is a hallmark of critical thinking. Explaining to the patient that self-reporting of severe pain is not consistent with the minor procedure that was performed: Pain is subjective and should always be believed and assessed rather than dismissed based on procedure type. This does not demonstrate critical thinking. Administering pain-relief medication according to what was given last shift: Pain levels fluctuate, and medication effectiveness must be reassessed each time. Simply repeating the previous shift’s orders does not involve critical thinking. Offering pain-relief medications based on the provider’s orders: While following orders is necessary, critical thinking involves assessing the patient’s pain level and determining the most appropriate intervention rather than blindly administering medication.
Question 3 of 5
The nurse is caring for a patient who has experienced a laparoscopic appendectomy. For which type of healing will the nurse focus the care plan?
Correct Answer: A
Rationale: Primary Intention: Primary intention healing occurs when surgical incisions are closed with sutures, staples, or adhesive strips. Since laparoscopic procedures involve small incisions that are closed immediately, this type of healing applies. Partial-thickness repair: Partial-thickness repair refers to wounds that involve only the epidermis and part of the dermis (e.g., abrasions, minor burns). Surgical incisions are full-thickness wounds, so this is not applicable. Secondary Intention: Secondary intention healing occurs when wounds heal from the inside out, typically seen in pressure ulcers, large open wounds, or infected wounds. Surgical wounds that are sutured do not heal by secondary intention. Tertiary Intention: Tertiary intention healing occurs when a wound is left open initially and later closed due to infection risk or delayed healing. Laparoscopic appendectomy wounds are closed immediately, making this choice incorrect.
Question 4 of 5
A nurse is providing preoperative teaching by demonstrating diaphragmatic breathing to a client who is scheduled for surgery in the morning. Which of the following actions should the nurse include in the demonstration?
Correct Answer: D
Rationale: Inhale slowly and evenly through her nose: The correct technique for diaphragmatic breathing is to inhale deeply through the nose while the abdomen expands. This promotes lung expansion and prevents atelectasis postoperatively. Hold her breath for at least 10 seconds: Diaphragmatic breathing focuses on slow, deep breaths to promote lung expansion and oxygenation. Holding the breath is not part of this technique and may increase discomfort. Place her hands on the sides of her rib cage: While hand placement is encouraged, the correct position is on the abdomen (below the rib cage), not the sides. This helps the client feel the diaphragm expanding. Exhale forcefully through the nose: Exhalation should be slow and controlled through the mouth, not forceful through the nose, to prevent airway irritation.
Question 5 of 5
The nurse is caring for a patient who has a wound drain with a collection device. The nurse notices that the collection device has a sudden decrease in drainage.
Correct Answer: A
Rationale: Call the health care provider, a blockage is present in the tubing: A sudden decrease in drainage can indicate a blockage in the tubing, which could lead to fluid buildup and infection. The provider should be notified so that interventions can be taken (e.g., irrigation, assessment for clot formation). Remove the drain, a drain is no longer needed: The nurse should not remove the drain without a provider’s order. A decrease in drainage does not necessarily mean the wound has healed. Do nothing as long as the evacuator is compressed: Even if the evacuator is compressed, a sudden decrease in drainage is abnormal and requires further investigation. Ignoring it can lead to complications like hematoma or infection. Chart the results on the intake and output flow sheet: While documenting the change is important, charting alone is not an appropriate intervention. The nurse must also assess for possible causes of the decreased drainage and notify the provider.