ATI RN
ATI Nursing 100 Day Exam 4 Fundamentals Questions
Extract:
Question 1 of 5
The nurse recognizes that the client is manifesting early signs of hypoxia when the assessment data includes:
Correct Answer: A
Rationale: Restlessness confusion and tachycardia are early hypoxia signs as the body compensates for low oxygen by increasing alertness and heart rate. Bradycardia cyanosis hypotension and lethargy indicate advanced hypoxia while vomiting is unrelated.
Question 2 of 5
The nurse is performing a dressing change for a patient and notices white skin around the wound edges. The nurse is aware that:
Correct Answer: B
Rationale: White skin around wound edges suggests nonviable tissue (maceration or necrosis) requiring surgical debridement to remove dead tissue and promote healing. Excessive moisture may contribute but is not the primary issue repositioning prevents pressure injuries not white skin and white skin is not a normal healing sign.
Question 3 of 5
The client has an open wound on the sacrum with an order for the following: Apply hydrogel dressing on the wound. Change dressing every day. The nurse recognizes that the primary purpose of this dressing is to:
Correct Answer: B
Rationale: Hydrogel dressings provide a moist environment to promote healing by facilitating autolytic debridement and granulation tissue formation. They do not primarily protect from pressure (handled by devices) enhance primary intention (for surgical wounds) or absorb drainage (hydrocolloids do this).
Question 4 of 5
An adult client is to receive ear drops four times a day to treat an inner ear infection. What is the correct nursing procedure to follow when administering this type of medication?
Correct Answer: C
Rationale: Pulling the auricle up and back straightens the ear canal in adults for effective ear drop administration ensuring medication reaches the inner ear. Down and back is for children pulling the earlobe post-instillation is unnecessary and microwaving risks burns.
Question 5 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.