ATI LEADERSHIP PROCTORED QEUSTIONS AND ANSWERS WITH RATIONALE

ATI LEADERSHIP PROCTORED QEUSTIONS AND ANSWERS WITH RATIONALE 1. A nurse is assessing pressure ulcers on four clients to evaluate the effectiveness of a change in the wound care procedure. Which of the following findings indicate wound healing. a. Erythema on the skin surrounding a client's wound b. Deep red color on the centre of the clients wound c. Inflammation noted on the tissue edges of a client's wound d. Increase in serosanguineous exudate from the clients' wound (damaged capillaries) Rationale: - Stages of Wound Healing - Inflammatory stage - beginning stage, also usually suggests infection - Begins with the injury and lasts 3 to 6 days - Effects to the wound: controlling bleeding with vasoconstriction and retraction of blood vessels, and with clot formation. Delivering oxygen, WBCs, nutrients to the area via the blood supply. Hemostasis occurs along with fibrin formation. Macrophages engulf microorganisms and cellular debris (phagocytosis). - Proliferative stage - Lasts the next 3 to 24 days - Effects to the wound: replacing lost tissue with connective or granulated tissue or collagen. Contracting the wound’s edges. Resurfacing of new epithelial cells. Healthy granulation tissue does not bleed easily. Dark granulation tissue can be a sign of infection, ischemia, or poor perfusion. In the final phase of the proliferative stage of wound healing, epithelial cells resurface the injury. - Maturation or remodelling stage - Occurs after day 21 and involves the strengthening of the collagen scar and restoration of a more normal appearance. It can take more than 1 year to complete, depending on the extent of the original wound. When scar tissues are forming. - Appearance: - Note the color of open wounds. - Red: healthy regeneration of tissue. - Yellow: the presence of purulent drainage and slough - Black: the presence of eschar that hinders healing and requires removal. 2. A nurse received change of shift report at 0700 for four clients. Which of the following actions should the nurse perform first? a. Obtain a breakfast tray for a client who received a morning dose of insulin aspart. - (fast-acting insulin...usually takes effect after 15 minutes) b. Administer pain medication to a client who has rheumatoid arthritis and received the last dose at 0400. c. Restart an infiltrated IV for a client whose IV antibiotic is scheduled for 0900 d. Replace a client's enteral nutrition feeding solution that has been hanging for 24 hours 3. A nurse is orienting a newly licensed nurse on the neurological unit. Which of the following clients should the nurse assign to the newly licensed nurse a. A client who has multiple sclerosis and ataxia - (normal finding for someone that has multiple sclerosis = most stable - showed up on online practice tests) b. A client who has a brain tumor and is admitted for chemotherapy c. A client who has guillain-barre syndrome and a tracheostomy -unstable d. A client who sustained a concussion and is being monitored for complication -unstable