ATI RN
ATI RN Fundamentals Online Practice 2023 B Questions
Extract:
A nurse is caring for a client who has COPD.The following are the client’s vital signs: Temperature 38.6C (101.5° F), BP 114/86 mm Hg, Heart rate 99/min, Respiratory rate 32/min, Oxygen saturation 85% on room air.
Question 1 of 5
Which three findings require follow-up?
Correct Answer: B,C,D
Rationale:
Choice A: Blood pressure of 114/86 mm Hg is normal.
Choice B: Oxygen saturation of 85% indicates hypoxemia.
Choice C: Temperature of 38.6°C suggests fever.
Choice D: Heart rate of 99/min indicates mild tachycardia.
Extract:
A nurse is caring for a client who has a peripheral IV inserted for fluid replacement.
On Day 1, Lactated Ringer’s was infusing at 100 mL/hr into a 20-gauge IV catheter in the left hand. The IV dressing was dry and intact.
The IV site was without redness or swelling. The IV fluid was infusing well.
On Day 2, the IV site was edematous.
The skin surrounding the catheter site was taut, blanched, and cool to touch. The IV fluid was not infusing.
The nurse is assessing the client.
Question 2 of 5
Which of the following actions should the nurse take?
Correct Answer: A,B,C
Rationale:
Choice A: Stopping the IV infusion prevents further tissue damage from infiltration.
Choice B: Elevating the arm reduces swelling.
Choice C: Applying heat promotes comfort and reduces swelling.
Choice D: Starting a new IV is premature before managing the infiltration.
Extract:
Nurses' Notes
The pressure injury on the sacrum was covered with slough and eschar. Debridement was performed.
The pressure injury was malodorous and at stage 4 with two tunnels present.
The pressure injury measured 10 cm (4 in) in diameter and 3 cm (1.2 in) at the deepest point.
The tunneling locations were at one and eight o’clock and measured at 6 cm (24 in) and 4 cm (1.6 in) respectively. The wound care nurse initiated negative pressure wound therapy.
Today, the client was sitting in bed, alert and oriented x. The client stated, “I can’t wait to get this thing off of me.”. The client reported pain as a 5 on a scale of 0 to 10. A PRN analgesic was prescribed.
At 0830, the client’s condition was assessed.
The client was at the bedside for a dressing change. S1 and S2 were auscultated, with a rate of 76/min. Respirations were even and regular at 16/min.
The negative pressure wound therapy dressing was removed.
Granulation tissue covered the wound bed. There was slight erythema.
The pressure injury measured 8.75 cm (3.5 in) in diameter and 2.5 cm (1 in) at the deepest point.
Two tunnels measured 5 cm (2 in) and 3 cm (1.2 in). The dressing was reapplied and sealed, with an intermittent pressure setting at 125 mm Hg. The client reported pain as a 2 on a scale from 0 to 10 and tolerated the procedure well.
Question 3 of 5
Three days ago, a client was admitted from home with a reported pressure injury. The provider and wound care nurse were at the bedside. Which statement best describes the most critical aspect of the client's pressure injury and current treatment?
Correct Answer: B
Rationale: The pressure injury was at stage 4. Stage 4 pressure ulcers involve full-thickness skin loss potentially extending into deeper tissues, requiring intensive treatment like debridement and negative pressure wound therapy.
Extract:
Question 4 of 5
A nurse is caring for a patient who is postoperative following a knee arthroplasty and requires the use of thigh-length sequential compression sleeves. Which of the following actions should the nurse take?
Correct Answer: C
Rationale: The nurse should ensure that two fingers can fit under the sleeves to ensure they are not too tight, which could impede blood flow and cause discomfort or injury.
Extract:
A client expresses anger when the nurse does not respond within 5 minutes of ringing for the nurse.
Question 5 of 5
Which response by the nurse is appropriate?
Correct Answer: C
Rationale: Saying 'That must be frustrating for you. How can I help you right now?' acknowledges the client's feelings of frustration and offers assistance, which is an appropriate response.