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: The correct answer is D: Stage II. In a Stage II pressure ulcer, there is a break in the skin that can manifest as a blister or shallow crater. The presence of erythema, serosanguineous drainage, and blister-like appearance in the sacral area indicates partial-thickness skin loss, characteristic of a Stage II pressure ulcer. This stage involves damage to the epidermis and/or dermis, with symptoms such as pain, warmth, and swelling.
Incorrect choices:
A: Stage IV – This stage involves full-thickness tissue loss with exposed bone, tendon, or muscle, which is not indicated by the described findings.
B: Stage III – This stage involves full-thickness tissue loss with visible fat, but the presence of a blister-like appearance suggests partial-thickness skin loss.
C: Stage I – This stage involves intact skin with non-blanchable erythema, not a break in the skin with blister-like features as described.
Question 2 of 5
Correct Answer:
Rationale:
Question 3 of 5
Correct Answer:
Rationale:
Question 4 of 5
Correct Answer:
Rationale:
Question 5 of 5
Correct Answer:
Rationale: