ATI RN
ATI Nursing 100 Day Exam 4 Fundamentals Questions
Extract:
Question 1 of 5
When doing the client's skin assessment the nurse notes a 3 cm area of partial thickness skin loss that looks like a blister on the client's sacral area. The nurse consults the wound care nurse who stages the wound as a pressure ulcer.
Correct Answer: B
Rationale: Partial thickness skin loss appearing as a blister indicates a Stage II pressure ulcer involving the epidermis and dermis. Stage I is intact skin with redness Stage III involves full-thickness loss and Stage IV includes deep tissue damage like muscle or bone.
Question 2 of 5
A client is recently diagnosed with pneumonia. The nurse observes the client sitting upright in the bed and assesses a respiratory rate of 26. The client states I can't catch my breath. Which abbreviation would be used to document this presentation?
Correct Answer: C
Rationale: SOB (shortness of breath) documents the client’s reported breathing difficulty and tachypnea aligning with pneumonia symptoms. R/O (rule out) is for tentative diagnoses S/P (status post) indicates past procedures and DOB (date of birth) is unrelated.
Question 3 of 5
A group that has transformed itself from a collection of individuals into a productive problem-solving highly functioning team would be functioning in which stage of group development?
Correct Answer: D
Rationale: The performing stage is where a group functions at its highest level with effective problem-solving and productivity. Forming involves initial introductions where members are polite and cautious storming includes conflict as members assert roles and norming establishes cohesion and norms but these stages do not reflect the high functionality and problem-solving described in the question.
Question 4 of 5
A nurse is caring for a client who has a diagnosis of alcohol withdrawal. Which serum laboratory value validates the client's admitting diagnosis? A serum:
Correct Answer: A
Rationale: Low magnesium (1.8 mEq/L below normal 1.8-2.5 mEq/L) is associated with alcohol withdrawal contributing to symptoms like tremors and seizures due to hypomagnesemia from poor nutrition and alcohol’s diuretic effect. Normal potassium (3.5-5.0 mEq/L) calcium (8.5-10.2 mg/dL) and phosphorus (2.5-4.5 mg/dL) levels do not specifically validate alcohol withdrawal.
Question 5 of 5
The nurse recognizes that the most appropriate reason to suction a client is that:
Correct Answer: D
Rationale: Suctioning is indicated when the client cannot clear secretions effectively as evidenced by gurgling respirations and inability to cough ensuring airway patency. Routine suctioning every eight hours or hourly without clinical need is inappropriate as it may cause trauma or discomfort. Coughing and swallowing sputum indicates effective airway clearance not requiring suctioning.