ATI RN
ATI Fundamentals Exam Special Unit ADN Questions
Extract:
Question 1 of 5
The nurse is completing a skin risk assessment using the Braden Scale. The patient has slight sensory impairment, has skin that is rarely moist, walks occasionally, and has slightly limited mobility, along with excellent intake of meals and no apparent problem with friction and shearing. Which score will the nurse document for this patient?
Correct Answer: D
Rationale: Sensory perception: Slightly limited (score of 3). Moisture: Rarely moist (score of 4). Activity: Walks occasionally (score of 3). Mobility: Slightly limited (score of 3). Nutrition: Excellent intake (score of 4). Friction and shear: No apparent problem (score of 3). Adding these scores together: 3 + 4 + 3 + 3 + 4 + 3 = 20.
Therefore, the nurse should document a score of 20 for this patient.
Question 2 of 5
A nurse teaches a patient about atelectasis. Which statement by the patient indicates an understanding of atelectasis?
Correct Answer: D
Rationale: It is important to do breathing exercises every hour to prevent atelectasis': Frequent deep breathing exercises, coughing, and incentive spirometry are essential for preventing atelectasis, especially after surgery. 'If I develop atelectasis, I will need a chest tube to drain excess fluid': Atelectasis is alveolar collapse, not fluid accumulation. Chest tubes are used for pneumothorax or pleural effusion, not for atelectasis. 'Hyperventilation will open up my alveoli, preventing atelectasis': Hyperventilation can cause respiratory alkalosis but does not effectively re-expand alveoli. Incentive spirometry and deep breathing are more effective. 'Atelectasis affects only those with chronic conditions such as emphysema': Atelectasis can affect anyone, especially postoperatively due to shallow breathing and reduced lung expansion. It is not exclusive to chronic conditions.
Question 3 of 5
While performing an assessment, the nurse hears crackles in the patient's lung fields. The nurse also learns that the patient is sleeping on three pillows to help with the difficulty breathing during the night. Which condition will the nurse most likely observe written in the patient's medical record?
Correct Answer: A
Rationale: Left-sided heart failure: Left-sided heart failure causes pulmonary congestion leading to crackles, orthopnea (difficulty breathing while lying flat), and paroxysmal nocturnal dyspnea (waking up gasping for air). Myocardial ischemia: Myocardial ischemia causes chest pain, shortness of breath, and fatigue, but it does not cause crackles in the lungs or fluid overload symptoms. Right-sided heart failure: Right-sided heart failure results in systemic congestion (peripheral edema, weight gain, and jugular vein distention), not pulmonary symptoms like crackles. Atrial fibrillation: Atrial fibrillation causes irregular heartbeats, palpitations, and fatigue, but it is not the primary cause of crackles or orthopnea.
Question 4 of 5
A nurse is observing a newly licensed nurse who is performing a focused skin assessment on a client who reports a skin condition. Which of the following questions by the newly licensed nurse requires intervention?
Correct Answer: A
Rationale: Have you had any changes in your diet?': While diet can impact skin health, this question is not the most relevant for an immediate skin assessment. More direct questions about onset, symptoms, and exacerbating factors should be prioritized. 'Does your skin condition keep you awake at night?': Pruritus (itching), pain, or discomfort from a skin condition can disrupt sleep. Asking this helps assess the impact on daily life and quality of sleep. 'How does your skin condition make you feel?': Skin conditions can affect self-esteem and mental health. This question is therapeutic and appropriate to assess emotional impact. 'How do you handle stress?': Many skin conditions, such as eczema and psoriasis, worsen with stress. This question is relevant for identifying triggers.
Question 5 of 5
A nurse is preparing to perform hand hygiene. Which of the following actions should the nurse take?
Correct Answer: C
Rationale: Apply 4 to 5 mL of liquid soap to the hands: The recommended amount of liquid soap is 3 to 5 mL to effectively remove microorganisms. Using too little may not clean adequately, and using too much can make rinsing difficult. Hold the hands higher than the elbows: Hands should be held lower than the elbows to allow water to flow from the fingertips downward, preventing contamination of clean areas by dirty water. Rub hands and arms to dry: Hands should be dried by patting rather than rubbing to prevent skin irritation. Also, drying should focus on the hands first, then the wrists, and then the forearms to avoid recontamination. Adjust the water temperature to feel hot: Water should be warm, not hot, to prevent skin irritation and dryness. Hot water can damage the skin’s natural protective barrier, increasing susceptibility to infection.