ATI RN
ATI Fundamentals Final Exam Questions
Extract:
Question 1 of 5
While performing a bed bath,the nurse notes an area of tissue injury on the client's sacral area. The wound presents as a shallow open ulcer with a red-pink wound bed and partial thickness loss of dermis. What is the correct name of this wound?
Correct Answer: A
Rationale: A stage II pressure ulcer is a wound that presents as a shallow open ulcer with a red-pink wound bed and partial thickness loss of the dermis caused by unrelieved pressure on the skin. Stage I involves non-blanchable erythema Stage III involves full-thickness skin loss and Stage IV involves full-thickness tissue loss with exposed muscle or bone making Stage II the correct classification for the described wound.
Question 2 of 5
A nurse is preparing a client for a physical assessment. The client appears anxious about the assessment. Which statement by the nurse would be most appropriate?
Correct Answer: B
Rationale: Explaining the procedure and reassuring the client that it should not be painful helps alleviate anxiety by providing information and comfort. Other statements may dismiss the client’s feelings or cause unnecessary worry.
Question 3 of 5
A client has been diagnosed with diabetes mellitus and must learn how to do his own finger stick blood sugar analysis as part of his treatment. The client has been sullen and uncommunicative since receiving the diagnosis. How can the nurse best increase the client's motivation to learn?
Correct Answer: A
Rationale: Encouraging the client's participation each time the procedure is performed can increase motivation by involving the client actively in their care fostering confidence and ownership. Other options such as performing the procedure for the client or teaching others may reduce the client's engagement and sense of responsibility.
Question 4 of 5
The nurse has performed an assessment of a client scheduled for discharge to be cared for by the family. Which situation would the nurse question regarding discharge of this client to be cared for by the family?
Correct Answer: B
Rationale: The nurse would question the discharge of a client to be cared for by the family if the client and family lack knowledge of the treatment regimen. Adequate understanding of the treatment regimen including medication administration wound care or device management is essential for safe and effective care at home. Without this knowledge the family may inadvertently cause harm necessitating further education or support before discharge. The other situations—sterile dressing changes feeding tube and IV medications by home health nurses—are manageable with proper training or professional support and do not inherently prevent discharge.
Question 5 of 5
A client recovering from surgery asks the nurse why turning,deep breathing and coughing exercises need to be done. How should the nurse respond?
Correct Answer: C
Rationale: Turning deep breathing and coughing exercises are important for clients recovering from surgery as they help prevent the development of pneumonia. After surgery clients may have difficulty taking deep breaths and coughing due to pain or discomfort which can lead to mucus accumulation in the lungs increasing the risk of pneumonia. These exercises help clear the lungs and reduce this risk making this the primary reason for their implementation.