ATI RN
ATI RN Fundamentals Online Practice 2023 B Questions
Extract:
A nurse is caring for a patient in a medical-surgical unit.
The patient’s current diagnoses include type 2 diabetes mellitus and a past medical history of a left below-the-knee amputation 5 years ago.
The nurse is at the patient’s bedside for a dressing change.
The patient’s heart sounds (S1 and S2) are auscultated, with a rate of 76/min. The patient’s respirations are even and regular at 16/min.
The negative pressure wound therapy dressing is removed. Granulation tissue covers the wound bed.
There is slight erythema at the wound edges. The surrounding tissue is warm to touch.
There is no odor present.
The pressure injury is 8.75 cm (3.5 in) in diameter and 2.5 cm (1 in) at the deepest point.
There are two tunnels measuring 5 cm (2 in) and 3 cm (1.2 in). The dressing is reapplied and sealed.
The intermittent pressure setting is at 125 mm Hg. The patient reports pain as a 2 on a scale from 0 to 10 and tolerated the procedure well.
Question 1 of 5
Which of the following findings indicate an improvement in the patient's condition?
Correct Answer: A
Rationale: The correct answer is A because granulation tissue covering the wound bed indicates healing progress by promoting tissue repair and regeneration. This is a positive sign of wound healing.
Choice B, slight erythema at wound edges, can indicate inflammation or infection, not necessarily improvement.
Choice C, warm surrounding tissue, could suggest infection or inflammation, not improvement.
Choice D, pain level 2, is subjective and doesn't directly indicate improvement in the condition.
Extract:
Question 2 of 5
The client is experiencing symptoms of itching and anxiety, and presents with a flushed face and hives. Complete the following sentence: 'The client's condition is indicative of _.'.
Correct Answer: A
Rationale: The correct answer is A: An allergic reaction. The symptoms described - itching, anxiety, flushed face, and hives - are classic signs of an allergic reaction. Itching and hives suggest a skin reaction, while anxiety can be a psychological response to the physical symptoms. Flushed face may indicate a systemic response. The presence of these symptoms together points towards an immune response triggered by an allergen.
Choices B, C, and D are incorrect as they do not align with the symptoms presented.
Choice B mentions side effects of a procedure, which would not typically cause these specific symptoms.
Choice C, anxiety disorder, does not explain the physical symptoms like itching and hives.
Choice D, hypersensitivity to IV gauge material, could be a potential cause, but the broader symptoms described are more indicative of an allergic reaction.
Extract:
A nurse is caring for a patient who has a respiratory infection.
Question 3 of 5
What technique should the nurse use when performing nasotracheal suctioning for the patient?
Correct Answer: B
Rationale: The correct answer is B: Apply intermittent suction when withdrawing the catheter. This technique helps prevent mucosal damage and hypoxia by reducing the risk of excessive suction pressure and prolonged suction time. Inserting the catheter while the patient is swallowing (
A) can lead to aspiration. Placing the catheter in a clean and dry location for later use (
C) is incorrect as it can lead to contamination. Holding the suction catheter with the non-dominant hand (
D) is not necessary for effective suctioning.
Extract:
A nurse is preparing to suction secretions from a patient who has a new tracheostomy.
Question 4 of 5
Which of the following actions should the nurse plan to take?
Correct Answer: B
Rationale: The correct answer is B: Select a suction catheter that is half the size of the lumen. This is because using a suction catheter that is half the size of the lumen allows for optimal suctioning efficiency without causing trauma to the patient's airway. A suction catheter that is too large can lead to tissue damage and ineffective suctioning.
Choice A is incorrect because using a resuscitation bag with 80% oxygen prior to the procedure is not related to proper suctioning technique.
Choice C is incorrect because placing the end of the suction catheter in water-soluble lubricant is not necessary and can introduce potential infection risks.
Choice D is incorrect because adjusting the wall suction apparatus to a pressure of 170 mm Hg is too high and can cause harm to the patient's airway.
Overall, selecting the appropriate size suction catheter is crucial for effective and safe suctioning procedures.
Extract:
A nurse is caring for a patient who has dementia
Question 5 of 5
What intervention should the nurse take to minimize the risk of injury to the patient?
Correct Answer: A
Rationale: The correct answer is A: Use a bed exit alarm system. This intervention helps to prevent patient falls by alerting the nurse when the patient attempts to leave the bed unsafely. It promotes early intervention and reduces the risk of injury. Raising four side rails (
B) may restrict the patient's movement excessively and could lead to entrapment. Applying a soft wrist restraint (
C) may cause discomfort and compromise the patient's circulation. Dimming the lights (
D) does not directly address the risk of injury.