ATI RN
ATI RN Fundamentals Online Practice 2023 B Questions
Extract:
Nurses' Notes
The pressure injury on the sacrum was covered with slough and eschar. Debridement was performed.
The pressure injury was malodorous and at stage 4 with two tunnels present.
The pressure injury measured 10 cm (4 in) in diameter and 3 cm (1.2 in) at the deepest point.
The tunneling locations were at one and eight o’clock and measured at 6 cm (24 in) and 4 cm (1.6 in) respectively. The wound care nurse initiated negative pressure wound therapy.
Today, the client was sitting in bed, alert and oriented x. The client stated, “I can’t wait to get this thing off of me.”. The client reported pain as a 5 on a scale of 0 to 10. A PRN analgesic was prescribed.
At 0830, the client’s condition was assessed.
The client was at the bedside for a dressing change. S1 and S2 were auscultated, with a rate of 76/min. Respirations were even and regular at 16/min.
The negative pressure wound therapy dressing was removed.
Granulation tissue covered the wound bed. There was slight erythema.
The pressure injury measured 8.75 cm (3.5 in) in diameter and 2.5 cm (1 in) at the deepest point.
Two tunnels measured 5 cm (2 in) and 3 cm (1.2 in). The dressing was reapplied and sealed, with an intermittent pressure setting at 125 mm Hg. The client reported pain as a 2 on a scale from 0 to 10 and tolerated the procedure well.
Question 1 of 5
Three days ago, a client was admitted from home with a reported pressure injury. The provider and wound care nurse were at the bedside. Which statement best describes the most critical aspect of the client's pressure injury and current treatment?
Correct Answer: B
Rationale: The pressure injury was at stage 4. Stage 4 pressure ulcers involve full-thickness skin loss potentially extending into deeper tissues, requiring intensive treatment like debridement and negative pressure wound therapy.
Extract:
A nurse is planning a teaching session for a group of adolescents who each recently had an ostomy surgically placed.
Question 2 of 5
Which of the following methods should the nurse use as a psychomotor approach to learning?
Correct Answer: D
Rationale: Role play is a method that falls under the psychomotor domain of learning. It involves acting out scenarios and provides an opportunity for hands-on practice and learning.
Extract:
Question 3 of 5
A nurse is caring for a client who has a prescription for 5 units of regular insulin and 10 units of NPH insulin to be mixed together and administered subcutaneously.Determine the correct order of steps for this procedure.
Correct Answer: C,A,D,B
Rationale: The correct order is: Inject 10 units of air into NPH insulin (
C), inject 5 units of air into regular insulin (
A), withdraw regular insulin (
D), withdraw NPH insulin (
B). This prevents contamination and ensures accurate dosing.
Question 4 of 5
A nurse is caring for a client who asks about the purpose of advance directives. Which of the following statements should the nurse make?
Correct Answer: B
Rationale: Advance directives indicate the form of treatment a client is willing to accept in the event of a serious illness, allowing individuals to express their preferences.
Question 5 of 5
A nurse is placing a patient on isolation precautions. Which of the following actions should the nurse take?
Correct Answer: A,B
Rationale:
Choice A: Wearing an N95 mask protects the nurse from airborne particles, appropriate for certain isolation precautions.
Choice B: Placing a container for soiled linens inside the room prevents the spread of infection.
Choice C: A sterile gown is not typically required unless performing a sterile procedure.
Choice D: Ventilation is important for airborne precautions but not standard for all isolation types.