Skills Exam ATI Study Set– Questions With Appropriate
Solutions
A nurse is caring for patient who has developed a stage I pressure ulcer in the
area of the right ischial tuberosity. Which of the following should the nurse
plan to apply to the ulcer Correct Answer - zinc oxide
It is a barrier cream
A nurse is caring for a patient who is admitted with multiple wounds
sustained in a motor vehicle crash. Understanding the patient's specific needs
during this initial stage of healing, the nurse should incorporate which into the
patient's care to prevent a prolongation of this phase? Correct Answer -
Apply oxygen at 2 L / min via nasal cannula
oxygen is essential to healing and some patients lack enough oxygen in these
states or have poor perfusion
A nurse is documenting data about a healing wound on a patient's lower leg.
The predominant exudate in the wound is watery in consistency and light red
in color. The nurse should document this exudate as Correct Answer -
serosanguineous
thin, watery-pink to light red in color
A nurse is documenting a deep necrotic wound on a patient's left buttock.
Nurse observes a yellowish, tan soft, stringy area of necrotic tissue formed in
clumps and adhering firmly to wound bed. The nurse should document this
type of necrotic tissue as Correct Answer - slough
A patient who has a full thickness wound continues to experience
considerable pain during dressing changes, despite administration of the
prescribed analgesic prior to wound care. Which of the following should the
nurse select to help minimize pain of dressing changes? Correct Answer -
Hydrogel
Hydrogel helps keep a moist environment which reduces pain
,A nurse is caring for a patient with a stage IV sacral pressure ulcer for which
the provider has prescribed mechanical debridement. Which of the following
should nurse plan for this patient? Correct Answer - Changing dressing
using the wet-to-dry method
Provides mechanical debridement when it is removed.
A nurse is caring for a patient who has a heavily draining wound that
continues to show evidence of bleeding. Which of the following types of
dressing should the nurse select to help promote hemostasis Correct
Answer - Alginate
Helps establish hemostasis while providing moisture for healing and good
absorption of exudate. They don't adhere to the wound and removal is
unlikely to cause bleeding.
A nurse is caring for a patient who has multiple sclerosis and has a chronic
non-healing wound. The nurse should recognize that which of the following
types of medications is known to delay wound healing? Correct Answer -
Corticosteroids
They suppress immune system and can delay wound healing
A nurse assessing a pressure ulcer over a patient's right heel area observes a
deep crater with no eschar or slough and no exposed muscle or bone. The
nurse should document that this patient has a pressure ulcer that is Correct
Answer - Stage III
When auscultating a patient's apical pulse, you listen until you hear the S1 and
S2 heart sounds clearly and regularly. S2 is produced when the... Correct
Answer - Semilunar Valves close
-The second heart sound, S2, is generated by the closure of the semilunar
valves (the aortic and pulmonic valve) and signals the start of diastole. S2 is
the "dub" heard in the normal "lub-dub" sound.
You are preparing to use a tympanic thermometer. Which of the following
steps has the highest priority in the accurate use of this piece of equipment for
, measuring body... Correct Answer - Gently pulling the pinna back and
upward
-A tympanic thermometer is probably not the best choice when the patient's
ears show signs of infection, inflammation, or trauma because of the risk of
further damage, pain, or contamination. But the device would still register
temperature accurately.
You are assessing the vital signs of a newly admitted patient. To establish an
accurate baseline of the patient's respiration you Correct Answer -
Observe the patient's chest movements while appearing to assess his pulse
-You are mostly likely to observe the true respiratory pattern (rate, rhythm,
and depth) when the patient is unaware that he is being assessed. When
patients know their respiration is being observed, it is common for them to
alter their respiratory pattern either voluntarily or involuntarily.
When assessing a patient's respiration, it is recommended that the patient...
Correct Answer - Have the head of the bed elevated 45 to 60 degrees
-This is a comfortable position for most patients and it allows full ventilatory
movement. Also, any type of discomfort can increase respiratory rate.
To auscultate a patient's apical pulse accurately, you position the bell or the
diaphragm on your stethoscope over the point of maximal impusel, which is
located... Correct Answer - at the fifth intercostal space at the left
midclavicular line
-To locate the point of maximal impulse, first located the angle of Louis - bony
prominence just below the suprasternal notch. Slide you fingers down each
side of the angle of Louis to locate the second intercostal space. Gently move
your fingers down the left side of the sternum to the fifth intercostal space and
laterally to the left midclavicular line. You have found the PMI.
The best way to determine the depth of a patient's respiration is to... Correct
Answer - observe the degree of chest wall movements during inspiration
and expiration
Solutions
A nurse is caring for patient who has developed a stage I pressure ulcer in the
area of the right ischial tuberosity. Which of the following should the nurse
plan to apply to the ulcer Correct Answer - zinc oxide
It is a barrier cream
A nurse is caring for a patient who is admitted with multiple wounds
sustained in a motor vehicle crash. Understanding the patient's specific needs
during this initial stage of healing, the nurse should incorporate which into the
patient's care to prevent a prolongation of this phase? Correct Answer -
Apply oxygen at 2 L / min via nasal cannula
oxygen is essential to healing and some patients lack enough oxygen in these
states or have poor perfusion
A nurse is documenting data about a healing wound on a patient's lower leg.
The predominant exudate in the wound is watery in consistency and light red
in color. The nurse should document this exudate as Correct Answer -
serosanguineous
thin, watery-pink to light red in color
A nurse is documenting a deep necrotic wound on a patient's left buttock.
Nurse observes a yellowish, tan soft, stringy area of necrotic tissue formed in
clumps and adhering firmly to wound bed. The nurse should document this
type of necrotic tissue as Correct Answer - slough
A patient who has a full thickness wound continues to experience
considerable pain during dressing changes, despite administration of the
prescribed analgesic prior to wound care. Which of the following should the
nurse select to help minimize pain of dressing changes? Correct Answer -
Hydrogel
Hydrogel helps keep a moist environment which reduces pain
,A nurse is caring for a patient with a stage IV sacral pressure ulcer for which
the provider has prescribed mechanical debridement. Which of the following
should nurse plan for this patient? Correct Answer - Changing dressing
using the wet-to-dry method
Provides mechanical debridement when it is removed.
A nurse is caring for a patient who has a heavily draining wound that
continues to show evidence of bleeding. Which of the following types of
dressing should the nurse select to help promote hemostasis Correct
Answer - Alginate
Helps establish hemostasis while providing moisture for healing and good
absorption of exudate. They don't adhere to the wound and removal is
unlikely to cause bleeding.
A nurse is caring for a patient who has multiple sclerosis and has a chronic
non-healing wound. The nurse should recognize that which of the following
types of medications is known to delay wound healing? Correct Answer -
Corticosteroids
They suppress immune system and can delay wound healing
A nurse assessing a pressure ulcer over a patient's right heel area observes a
deep crater with no eschar or slough and no exposed muscle or bone. The
nurse should document that this patient has a pressure ulcer that is Correct
Answer - Stage III
When auscultating a patient's apical pulse, you listen until you hear the S1 and
S2 heart sounds clearly and regularly. S2 is produced when the... Correct
Answer - Semilunar Valves close
-The second heart sound, S2, is generated by the closure of the semilunar
valves (the aortic and pulmonic valve) and signals the start of diastole. S2 is
the "dub" heard in the normal "lub-dub" sound.
You are preparing to use a tympanic thermometer. Which of the following
steps has the highest priority in the accurate use of this piece of equipment for
, measuring body... Correct Answer - Gently pulling the pinna back and
upward
-A tympanic thermometer is probably not the best choice when the patient's
ears show signs of infection, inflammation, or trauma because of the risk of
further damage, pain, or contamination. But the device would still register
temperature accurately.
You are assessing the vital signs of a newly admitted patient. To establish an
accurate baseline of the patient's respiration you Correct Answer -
Observe the patient's chest movements while appearing to assess his pulse
-You are mostly likely to observe the true respiratory pattern (rate, rhythm,
and depth) when the patient is unaware that he is being assessed. When
patients know their respiration is being observed, it is common for them to
alter their respiratory pattern either voluntarily or involuntarily.
When assessing a patient's respiration, it is recommended that the patient...
Correct Answer - Have the head of the bed elevated 45 to 60 degrees
-This is a comfortable position for most patients and it allows full ventilatory
movement. Also, any type of discomfort can increase respiratory rate.
To auscultate a patient's apical pulse accurately, you position the bell or the
diaphragm on your stethoscope over the point of maximal impusel, which is
located... Correct Answer - at the fifth intercostal space at the left
midclavicular line
-To locate the point of maximal impulse, first located the angle of Louis - bony
prominence just below the suprasternal notch. Slide you fingers down each
side of the angle of Louis to locate the second intercostal space. Gently move
your fingers down the left side of the sternum to the fifth intercostal space and
laterally to the left midclavicular line. You have found the PMI.
The best way to determine the depth of a patient's respiration is to... Correct
Answer - observe the degree of chest wall movements during inspiration
and expiration
