ATI RN
ATI Fundamentals Exam Special Unit ADN Questions
Extract:
Question 1 of 5
Which finding will alert the nurse to a potential wound dehiscence?
Correct Answer: A
Rationale: Report by patient that something has given way: A patient reporting a 'giving way' sensation is a classic early sign of dehiscence, indicating that the wound edges are separating. Drainage that is odorous and purulent: Purulent (pus-like) and foul-smelling drainage suggests infection, not necessarily dehiscence. Infection can contribute to dehiscence, but it is not the defining feature. Protrusion of visceral organs through a wound opening: Evisceration occurs when internal organs protrude through the incision. Dehiscence is partial or complete separation of the wound edges without organ protrusion. Chronic drainage of fluid through the incision site: Persistent drainage suggests a fistula (abnormal connection between tissues), infection, or poor wound healing, rather than wound dehiscence.
Question 2 of 5
A patient has been diagnosed with heart failure and cardiac output is decreased. Which formula can the nurse use to calculate cardiac output?
Correct Answer: C
Rationale: Stroke volume × heart rate: Cardiac Output (CO) = Stroke Volume (SV) × Heart Rate (HR). Stroke volume is the amount of blood pumped per beat, and heart rate is the number of beats per minute. Multiplying these values gives the total volume of blood pumped per minute, making this the correct formula. Myocardial contractility × myocardial blood flow: While myocardial contractility and blood flow affect cardiac output, they are not part of the formula for calculating it. Ventricular filling time/diastolic filling time: This ratio does not determine cardiac output. While diastolic filling time affects stroke volume, it is not the standard formula for cardiac output. Preload/afterload: Preload and afterload influence cardiac function but are not used to directly calculate cardiac output.
Question 3 of 5
A nurse on the telemetry(cardiac unit) is caring for a client who has unstable angina and is reporting chest pain with a severity of 6 on a 0-10 pain scale. The nurse administers 1 nitroglycerin (sublingual). After 5 minutes, the client states that his chest pain is now a severity of 2. Which of the following actions Should the nurse take?
Correct Answer: C
Rationale: Obtain an ECG/EKG: Even though the pain improved, unstable angina can progress to myocardial infarction. An ECG helps evaluate for ischemic changes and ensures the pain is truly resolving. Initiate a peripheral IV: While an IV line is useful for medication administration, the patient’s pain has significantly improved with nitroglycerin. An IV may be necessary later, but it is not the next step in this scenario. Administer another nitroglycerin tablet: Nitroglycerin can be repeated every 5 minutes up to 3 doses if chest pain persists or does not decrease significantly. Since the pain has improved (from 6 to 2), additional nitroglycerin is unnecessary. Call the Rapid Response Team (RRT): RRT should be called for worsening chest pain, unresponsiveness, or hemodynamic instability. Since the pain has improved, calling RRT is unnecessary.
Question 4 of 5
A school nurse identifies that a child has pediculosis capitis and educates the child's parents about the condition. Which of the following statements by the parents indicates an understanding of the teaching?
Correct Answer: D
Rationale: All recently used clothing, bedding, and towels must be washed in hot water': Lice and nits can survive on fabric surfaces, so washing clothing, bedding, and towels in hot water (≥130°F/54°
C) and drying on high heat is recommended to eliminate them. 'I will treat all the family members to be on the safe side': Treatment is only recommended for individuals who have active lice or close, prolonged contact with the infected child. Treating everyone unnecessarily may lead to overuse of medications. 'My child must be free from nits before returning to school': The CDC and AAP do not recommend 'no-nit' policies, as nits alone do not indicate active infestation. Children can return to school after appropriate treatment begins. '
Toys that can't be dry cleaned or washed must be thrown out': Non-washable items should be sealed in a plastic bag for 2 weeks to kill lice, rather than being thrown away.
Question 5 of 5
A nurse is using professional standards to influence clinical decisions. What is the rationale for the nurse's actions?
Correct Answer: C
Rationale: Uses critical thinking for the highest level of quality nursing care: Professional standards provide guidelines for best practices, ensuring nurses apply critical thinking and clinical judgment to improve patient outcomes. Utilizing evidence-based practice based on nurses' needs: Professional standards focus on patient-centered care, not the nurse's needs. Evidence-based practice should prioritize patient safety and effectiveness. Establishes minimal passing standards for testing: While professional standards guide nursing education and testing, their primary role is to guide clinical decision-making for patient care. Bypasses the patient's feelings to promote ethical standards: Ethical nursing practice includes patient advocacy, not bypassing patient emotions or concerns.