ATI RN
ATI Fundamentals Exam Special Unit ADN Questions
Extract:
Question 1 of 5
The patient requires temperatures to be taken every 2 hours. Which task will be the responsibility of the RN?
Correct Answer: A
Rationale: Assessing changes in body temperature: The RN is responsible for assessing trends in temperature and identifying potential clinical implications (e.g., infection, sepsis, or medication reactions). Being aware of the usual values for the patient: While knowing baseline values is important, this is not solely an RN responsibility. Nursing assistants and other healthcare providers also note baseline values. Obtaining temperature measurements at ordered frequency: This task can be delegated to a nursing assistant or licensed practical nurse (LPN), as it is a routine task that does not require assessment. Using an appropriate route and device: While the RN ensures correct procedures are followed, this specific task can also be performed by trained assistive personnel. The RN focuses on interpretation and intervention.
Question 2 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 3 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.
Question 4 of 5
A nurse participating in a research project associated with pressure ulcers will assess for what predisposing factor that tends to increase the risk for pressure ulcer development?
Correct Answer: C
Rationale: Decreased level of consciousness: Patients with a decreased level of consciousness (e.g., sedated, comatose, or confused patients) are at higher risk for pressure ulcers due to immobility, lack of repositioning, and unawareness of discomfort. Shortness of breath: While respiratory issues can reduce oxygenation and indirectly affect healing, shortness of breath is not a direct risk factor for pressure ulcer development. Adequate dietary intake: Adequate nutrition prevents pressure ulcers rather than increasing the risk. Poor dietary intake, particularly protein and vitamin deficiencies, is a risk factor. Muscular pain: While pain can limit movement, it is not a primary risk factor for pressure ulcer development. Immobility and prolonged pressure are the key contributors.
Question 5 of 5
The nurse is preparing to assess the blood pressure of a 3-year-old. How should the nurse proceed?
Correct Answer: A
Rationale: Explain the procedure to the child: Explaining procedures in an age-appropriate manner helps reduce anxiety and increases cooperation. A 3-year-old can understand simple instructions, so explaining what will happen can help them remain calm. Choose the cuff that says 'Child' instead of 'Infant': Blood pressure cuffs should be appropriately sized for accurate readings. A cuff that is too small can result in falsely high readings, while a cuff that is too large can produce falsely low readings. Use the diaphragm portion of the stethoscope to detect Korotkoff sounds: The bell of the stethoscope is best for detecting low-pitched sounds, including Korotkoff sounds. Obtain the reading before the child has a chance to settle down: A child who is upset, crying, or anxious may have an elevated blood pressure reading due to stress. It is best to allow the child to calm down before obtaining an accurate measurement.