ATI RN
ATI Fundamentals Assessment Exam Midterm Questions
Extract:
Question 1 of 5
When asked to assess an area of broken skin on an older adult client in a long-term care facility, the nurse notes a break in the skin with erythema and a small amount of serosanguineous drainage over the sacrum. The area appears blister-like. The nurse would interpret this finding as indicating which stage of pressure ulcer?
Correct Answer: D
Rationale: Stage II pressure ulcers involve partial-thickness skin loss, presenting as a shallow ulcer or blister with a red-pink wound bed, matching the description of erythema, serosanguineous drainage, and a blister-like appearance. Stage I has intact skin with non-blanchable redness, Stage III extends to subcutaneous tissue with a crater-like appearance, and Stage IV involves full-thickness loss with exposed bone or muscle.
Question 2 of 5
When asked to assess an area of broken skin on an older adult client in a long-term care facility, the nurse notes a break in the skin with erythema and a small amount of serosanguineous drainage over the sacrum. The area appears blister-like. The nurse would interpret this finding as indicating which stage of pressure ulcer?
Correct Answer: D
Rationale: Stage II pressure ulcers involve partial-thickness skin loss, presenting as a shallow ulcer or blister with a red-pink wound bed, matching the description of erythema, serosanguineous drainage, and a blister-like appearance. Stage I has intact skin with non-blanchable redness, Stage III extends to subcutaneous tissue with a crater-like appearance, and Stage IV involves full-thickness loss with exposed bone or muscle.
Question 3 of 5
While examining a client, the nurse observes the client's chest to be barrel-shaped. The nurse would interpret this as indicating which of the following?
Correct Answer: D
Rationale: A barrel-shaped chest results from chronic lung hyperinflation in COPD, expanding the rib cage. Pigeon chest (pectus carinatum) protrudes, funnel chest (pectus excavatum) depresses, and pneumonia causes consolidation, not this shape.
Question 4 of 5
A nurse is assessing a 64-year-old African-American client who has jaundice. The patient has a past medical history of alcoholism and liver cirrhosis. Which of the following areas is the most reliable for the nurse to inspect for jaundice?
Correct Answer: B
Rationale: The sclera’s white background clearly shows yellowing (scleral icterus), making it the most reliable for jaundice, especially in darker skin. Conjunctiva, neck, and palms are less consistent due to external factors or pigmentation.
Question 5 of 5
Prior to completing the physical examination of a patient post motor vehicle crash, the ER nurse determines that the client is awake, alert, and oriented. This information would be important for which part of the general survey?
Correct Answer: B
Rationale: Being awake, alert, and oriented assesses level of consciousness, critical post-trauma to establish cognitive function and detect neurological changes. Facial expression, posture/gait, and health state assess other survey components.