ATI RN
ATI Nursing 100 Day Exam 4 Fundamentals Questions
Extract:
Question 1 of 5
Which nursing action is most helpful in thinning a client's thick respiratory secretions?
Correct Answer: D
Rationale: Adequate fluid intake thins respiratory secretions by promoting hydration and mobilizing mucus reducing viscosity and aiding expectoration. Oxygen therapy supports oxygenation but not secretion thinning consistent air temperature has minimal impact and supine positioning may worsen secretion clearance by promoting stasis.
Question 2 of 5
On admission to the hospital the nurse notes that the client has a sacral wound that is yellow in color. What wound treatment would the nurse expect the health care provider to order?
Correct Answer: B
Rationale: A yellow wound indicates slough (nonviable tissue) requiring debridement to remove dead tissue and moist dressings to promote healing by maintaining a moist environment conducive to tissue regeneration. Oxygenation does not address slough barrier creams are for prevention and no treatment risks infection and delayed healing.
Question 3 of 5
A client has a serum potassium level of 6.3 mEq/L. The nurse recognizes that the highest priority intervention(s) for this client are to:
Correct Answer: C,E
Rationale: Hyperkalemia (6.3 mEq/L above normal 3.5-5.0 mEq/L) risks cardiac dysrhythmias and neuromuscular issues requiring immediate assessment for muscle weakness/flaccid paralysis and cardiac monitoring to detect life-threatening arrhythmias. Diluting potassium or encouraging potassium-rich foods worsens hyperkalemia and intake/output monitoring is secondary.
Question 4 of 5
The nurse is assessing a client who exhibits positive Trousseau's and Chvostek's signs. What laboratory value would validate these clinical findings? A serum:
Correct Answer: D
Rationale: Low calcium (6.9 mg/dL below normal 8.5-10.2 mg/dL) causes neuromuscular excitability leading to Trousseau’s (arm spasm with cuff inflation) and Chvostek’s (facial twitching) signs. Normal potassium (3.5-5.0 mEq/L) phosphate (2.5-4.5 mg/dL) and magnesium (1.8-2.5 mEq/L) do not explain these findings.
Question 5 of 5
The nurse has applied a topical agent to the client's skin and then applies an ice pack to the area. This is done to:
Correct Answer: B
Rationale: An ice pack slows topical drug absorption by causing vasoconstriction which reduces blood flow to the area allowing prolonged local action of the medication. It is not primarily used for comfort as cooling may not always reduce discomfort. Drug excretion is not affected by topical ice and maximizing distribution would require increased blood flow not reduction.