ATI Custom NUR125 Exam 2 Summer
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Free ATI Custom NUR125 Exam 2 Summer Questions
The nurse is providing oral care to an unconscious client. Which action is the priority to protect the client?
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Moisten the mouth using lemon-glycerin sponges.
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Use foam swabs to help remove plaque.
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Suction the oral cavity as needed.
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Hold the client's mouth open with gloved fingers.
Explanation
The greatest risk during oral care for an unconscious client is aspiration. Because the client lacks a protective gag reflex and cannot manage secretions independently, suctioning the oral cavity as needed is the priority action to prevent fluid, saliva, or oral care products from entering the airway and causing aspiration pneumonia. All other oral care interventions are secondary to maintaining airway safety.
Why the other options are incorrect:
A. Moisten the mouth using lemon-glycerin sponges — Lemon-glycerin swabs are actually not recommended for routine oral care as they can dry oral mucosa over time and erode tooth enamel. More importantly, this action does not address the primary safety risk of aspiration in an unconscious client.
B. Use foam swabs to help remove plaque — Foam swabs are useful for oral hygiene in unconscious clients but are less effective at plaque removal than a toothbrush. More critically, this action must be paired with suctioning to prevent aspiration of loosened debris and does not independently protect the airway.
D. Hold the client's mouth open with gloved fingers — Holding the mouth open with fingers risks injury to both the client and the nurse, particularly if the client has any reflex biting response. This is not a recommended technique and does not constitute a safety priority in oral care.
A nurse finds the client on the floor after an unwitnessed fall. What is the nurse's first action?
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Ensure the event is accurately documented in the patient's electronic record
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Assess the client for injury
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Complete an incident report
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Notify the healthcare provider immediately of the fall
Explanation
The nurse's first action after finding a client on the floor following an unwitnessed fall is to assess the client for injury. This follows the ABCs of nursing priority — the client's immediate safety and physical condition must be determined before any administrative or reporting actions are taken. The nurse must check for head injury, fractures, bleeding, pain, and neurological status before moving the client or completing any documentation.
Why the other options are incorrect:
A. Ensure the event is accurately documented in the patient's electronic record — Documentation is essential but is completed after the client has been assessed and stabilized. Prioritizing documentation over client assessment would be unsafe and inappropriate.
C. Complete an incident report — An incident report is an important risk management tool but is an administrative task that follows client assessment and care. It should never take priority over direct patient evaluation after a fall.
D. Notify the healthcare provider immediately of the fall — While notifying the provider is necessary and should occur promptly, the nurse must first assess the client to provide the provider with accurate and complete information about the client's condition and any injuries sustained.
A nurse is collecting the health history of a 70-year-old client with recent increased episodes of anxiety and confusion during their morning routine. Which finding indicates a safety risk that requires the nurse's immediate attention?
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Asks for questions to be repeated often during the interview
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Reports routine morning walks that lead to unfamiliar locations
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Repeatedly asks to go home and care for infant son
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Requiring assistance with transferring and positioning the client on the exam table
Explanation
A 70-year-old client with anxiety and confusion who reports becoming lost during familiar morning walks is demonstrating a significant and immediate safety risk. Getting lost in familiar environments is a classic sign of cognitive decline, such as early dementia, and places the client at serious risk for wandering, exposure, traffic accidents, and inability to return home safely. This requires immediate nursing attention and further cognitive assessment.
Why the other options are incorrect:
A. Asks for questions to be repeated often during the interview — Asking for repetition may reflect hearing impairment, which is common in older adults and warrants assessment, but it does not represent an immediate safety risk requiring urgent intervention.
C. Repeatedly asks to go home and care for infant son — While this reflects disorientation and possible cognitive impairment, it is not as immediately dangerous as physically wandering into unfamiliar locations where the client is at risk for harm in the community.
D. Requiring assistance with transferring and positioning the client on the exam table — This indicates a mobility limitation that requires fall precautions, but it is a manageable finding within the clinical setting and does not represent the most urgent safety concern compared to unsupervised wandering.
A nurse is caring for a group of clients. Which of the following clients should the nurse identify as the highest risk for developing a pressure injury?
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A client who makes frequent slight changes in position and walks occasionally
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A client with chronic kidney disease receiving dialysis who repositions independently
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A client who is unresponsive to verbal commands and changes position occasionally
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A client who is alert and responsive and eats 50% of each meal
Explanation
A client who is unresponsive to verbal commands has severely impaired sensory perception, meaning they cannot feel or respond to pain or discomfort caused by prolonged pressure. Combined with only occasional position changes, this client has significantly reduced ability to sense the need to reposition and cannot do so independently or on command. These two factors — impaired sensory perception and severely limited mobility — are the highest-risk combination for pressure injury development on the Braden Scale.
Why the other options are incorrect:
A. A client who makes frequent slight changes in position and walks occasionally — This client demonstrates some preserved mobility and activity, both of which are protective factors against pressure injury. Frequent repositioning, even slight changes, significantly reduces sustained pressure on any one area.
B. A client with chronic kidney disease receiving dialysis who repositions independently — While chronic kidney disease can affect skin integrity and healing, this client is able to reposition independently, which is a major protective factor that substantially reduces pressure injury risk.
D. A client who is alert and responsive and eats 50% of each meal — This client has intact cognition and sensory perception, allowing them to feel and respond to discomfort and reposition themselves. While eating only 50% of meals indicates some nutritional risk, the preserved ability to respond to pressure and reposition independently lowers the overall risk compared to option C.
A wound care nurse is caring for a client with a pressure injury.
Medical History
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Stage 2; Partial-thickness loss of skin
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Stage 3; Full-thickness loss of skin
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Stage 1; Superficial skin loss
Explanation
A Stage 2 pressure injury is characterized by partial-thickness loss of skin involving the epidermis and/or dermis. It presents as a shallow open wound with a red-pink wound bed, or as an intact or ruptured serum-filled blister. The nurse's notes describe exactly this — an exposed dermis and an intact serum-filled blister on the right hip — which are the defining clinical features of a Stage 2 pressure injury. The client's immobility, obesity, and decreased cardiac output are all contributing risk factors that further support this finding.
Why the other options are incorrect:
Stage 1 — A Stage 1 pressure injury presents as intact skin with non-blanchable redness over a localized area, typically over a bony prominence. There is no skin breakdown, blistering, or exposed dermis. The findings described in this case go beyond Stage 1.
Stage 3 — A Stage 3 pressure injury involves full-thickness skin loss where subcutaneous fat may be visible, but bone, tendon, and muscle are not exposed. The wound described here shows only an exposed dermis with a blister, which does not extend to the subcutaneous tissue layer required for Stage 3 classification.
Full-thickness loss of skin — Full-thickness skin loss is the hallmark of Stage 3 and Stage 4 pressure injuries, involving loss of the epidermis, dermis, and deeper tissue layers. The findings in this case involve only partial-thickness loss, not full-thickness loss.
Superficial skin loss — While a Stage 2 injury is relatively shallow, the correct and precise clinical term for the tissue loss seen in Stage 2 pressure injuries is partial-thickness loss of skin, not simply superficial skin loss. Partial-thickness specifically indicates that the epidermis and part of the dermis are involved, which aligns with the exposed dermis and intact blister described.
The nurse is caring for a client who refuses to bathe in the morning. When asked why, the client responds "I always bathe in the evening." Which of the following actions by the nurse is the most appropriate?
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Defer the bath until evening and pass on the client's preference to the next shift.
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Document that the hygiene was not performed and attempt again the next day.
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Explain the importance of maintaining morning hygiene practices.
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Advise the client that bath times are organized in advance to promote efficiency.
Explanation
Client-centered care requires that nurses respect individual preferences, routines, and cultural practices whenever clinically possible. Bathing in the evening rather than the morning is a personal preference that poses no clinical risk. Deferring the bath and communicating this preference in handoff report ensures continuity of care and demonstrates respect for the client's autonomy and established routine.
Why the other options are incorrect:
B. Document that the hygiene was not performed and attempt again the next day — Documenting hygiene as not performed without noting the reason or arranging for evening care fails the client and does not reflect person-centered practice. It also leaves the client without hygiene care for a full day unnecessarily.
C. Explain the importance of maintaining morning hygiene practices — There is no clinical evidence that morning bathing is superior to evening bathing. Attempting to persuade the client to change a longstanding personal routine disregards their autonomy and is not appropriate when the preference carries no clinical risk.
D. Advise the client that bath times are organized in advance to promote efficiency — Prioritizing unit efficiency over the client's established personal routine is not client-centered care. Schedules should be adapted to accommodate client preferences when possible, not the other way around.
A nurse is using the Braden Scale to assist in the assessment of a newly admitted client. Which of the following does the Braden Scale assess?
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Stage of pressure injury
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Risk for pressure injury
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Risk for falls
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Level of consciousness
Explanation
A nurse is planning morning care for several clients. Which of the following clients would the nurse assist with a bath first?
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A client in bed incontinent with watery stools
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A client with a stage 1 pressure injury
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An immobilized client who needs assistance with hygiene
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A client without a bath 2 days past admission
Explanation
A client who is incontinent of watery stool is the highest priority for immediate bathing. Fecal matter on the skin — especially liquid stool — contains microorganisms and digestive enzymes that rapidly break down skin integrity, causing incontinence-associated dermatitis and significantly increasing the risk of pressure injury and infection. Prompt cleansing is essential to protect skin integrity and prevent serious complications.
Why the other options are incorrect:
B. A client with a stage 1 pressure injury — A stage 1 pressure injury involves intact skin with non-blanchable redness. While this client requires careful skin care and repositioning, the condition is not as acutely time-sensitive as fecal incontinence actively damaging the skin.
C. An immobilized client who needs assistance with hygiene — While immobile clients are at elevated risk for skin breakdown and do require timely hygiene care, the absence of an acute skin threat such as fecal incontinence makes this client a lower priority than option A.
D. A client without a bath 2 days past admission — While attending to this client's hygiene needs is important for comfort and skin health, being without a bath for 2 days does not represent an immediate or acute skin integrity threat compared to active fecal incontinence.
A nurse is assessing a client who has impaired mobility. The nurse should monitor the client for a pressure injury due to which of the following factors?
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Increased metabolic rate
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Decreased motivation
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Impaired circulation
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Urinary stasis
Explanation
Pressure injuries develop when sustained mechanical pressure compresses blood vessels, reducing or cutting off blood flow to the skin and underlying tissues. In clients with impaired mobility, the inability to reposition frequently leads to prolonged pressure on bony prominences. Impaired circulation — whether from the pressure itself or from underlying vascular conditions — is the direct physiological mechanism by which tissue ischemia and subsequent pressure injury occur.
Why the other options are incorrect:
A. Increased metabolic rate — Immobility typically leads to a decreased metabolic rate over time, not an increased one. While altered metabolism affects overall healing capacity, it is not the primary factor linking impaired mobility to pressure injury development.
B. Decreased motivation — While decreased motivation may contribute to reluctance to reposition or participate in care, it is a psychosocial factor rather than the direct physiological cause of pressure injury in an immobile client.
D. Urinary stasis — Urinary stasis is a serious complication of immobility related to incomplete bladder emptying and increased UTI risk. While urinary incontinence can contribute to skin breakdown, urinary stasis itself is not the primary factor responsible for pressure injury development.
The nurse is caring for a client with impaired physical mobility. Which of the following is this client at risk of developing?
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Increased venous return in lower extremities leading to blood clots
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Decreased or absent bowel sounds leading to constipation
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Decreased lung expansion leading to retained secretions and pneumonia
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Increased urinary output leading to dehydration
Explanation
Immobility significantly impairs respiratory function. When a client cannot move freely, shallow breathing and reduced lung expansion lead to poor ventilation of the lung bases. This causes mucus and secretions to pool in the airways, creating an ideal environment for bacterial growth and increasing the risk of pneumonia and atelectasis. This is one of the most serious and well-documented complications of impaired physical mobility.
Why the other options are incorrect:
A. Increased venous return in lower extremities leading to blood clots — Immobility actually causes decreased venous return, not increased. Reduced muscle activity in the lower extremities impairs the venous pump mechanism, causing blood to stagnate in the veins and increasing the risk of deep vein thrombosis.
B. Decreased or absent bowel sounds leading to constipation — While constipation is a valid complication of immobility due to decreased peristalsis, the statement is partially incorrect. It is reduced peristalsis, not absent bowel sounds, that leads to constipation in immobile clients. Absent bowel sounds would indicate a more serious condition such as ileus.
D. Increased urinary output leading to dehydration — Immobility does not cause increased urinary output. Rather, it leads to urinary stasis, incomplete bladder emptying, and increased risk of urinary tract infections and kidney stones due to calcium being released from inactive bones increasing urinary calcium concentration.
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