ATI RN
ATI Fundamentals Exam Special Unit ADN Questions
Extract:
Question 1 of 5
The nurse is completing an assessment of the patient's skin integrity. Which assessment is the priority?
Correct Answer: A
Rationale: Pressure points: Pressure points (e.g., sacrum, heels, elbows, shoulders, hips) are at the highest risk for breakdown, ulcers, and impaired circulation. This makes them the priority assessment for skin integrity. Pulse points: While checking pulses is important for circulatory assessment, it is not directly related to skin integrity assessment. Breath sounds: Breath sounds assess respiratory function and are not a direct indicator of skin integrity. Bowel sounds: Bowel sounds assess gastrointestinal function and are not relevant in a skin integrity assessment.
Question 2 of 5
The nurse admitting an older patient notes a shallow open reddish, pink ulcer without slough on the right heel of the patient. How will the nurse stage this pressure ulcer?
Correct Answer: D
Rationale: Stage II: Stage II pressure ulcers involve partial-thickness skin loss with a shallow open wound, pink/red wound bed, and no slough. The given description matches Stage II. Stage IV: Stage IV ulcers involve full-thickness skin loss with exposed bone, tendon, or muscle. Since this ulcer is shallow and pink without slough, it is not Stage IV. Stage I: Stage I ulcers are intact skin with non-blanchable erythema. Since the ulcer is open, it is not Stage I. Stage III: Stage III ulcers have full-thickness tissue loss, possibly exposing subcutaneous fat. The given description lacks fat exposure or depth, ruling out Stage III.
Question 3 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 4 of 5
Your patient drunk 150 mL of Ice Tea. How many ounces is this?
Correct Answer: 5
Rationale: Solution: 1 ounce = 30 mL, so 150 mL ÷ 30 mL/oz = 5 oz. Answer: 5 ounces.
Question 5 of 5
A nurse is teaching a client about taking diphenhydramine. The nurse should explain to the client that which of the following is an adverse effect of this medication?
Correct Answer: D
Rationale: Sedation: Diphenhydramine is a first-generation antihistamine that crosses the blood-brain barrier and has a sedative effect by blocking histamine receptors in the central nervous system. It is commonly used as a sleep aid for this reason. Hypertension: Diphenhydramine (Benadryl) is an antihistamine that typically causes hypotension, not hypertension. It can have a mild vasodilatory effect, leading to a drop in blood pressure in some patients. Constipation: While some antihistamines can cause mild gastrointestinal effects, constipation is not a primary adverse effect of diphenhydramine. Dry mouth and urinary retention are more common due to its anticholinergic properties. Bradycardia: Diphenhydramine can sometimes cause tachycardia (increased heart rate), especially in elderly patients or those prone to cardiovascular effects. Bradycardia (slow heart rate) is not a usual adverse effect.