ATI MATERNAL NEWBORN PROCTORED EXAM Grade
A+
1. The nurse is caring for a patient who is immobile. The nurse wants to
decrease the formation of pressure ulcers. Which action will the nurse take
first?
a. Offer favorite fluids.
b. Turn the patient every 2 hours.
c. Determine the patient’s risk factors.
d. Encourage increased quantities of carbohydrates and fats.
ANS: C
The first step in prevention is to assess the patient’s risk factors for pressure
ulcer development. When a patient is immobile, the major risk to the skin is the
formation of pressure ulcers. Nursing interventions focus on prevention.
Offering favorite fluids, turning, and increasing carbohydrates and fats are not
the first steps.
Determining risk factors is first so interventions can be implemented to reduce
or eliminate those risk factors.
2. The medical-surgical acute care patient has received a nursing diagnosis
of Impaired skin integrity. Which health care team member will the nurse
consult?
a. Respiratory therapist
b. Registered dietitian
c. Case manager
d. Chaplain
ANS: B
Refer patients with pressure ulcers to the dietitian for early intervention for 191
nutritional problems. Adequate calories, protein, vitamins, and minerals
promote wound healing for the impaired skin integrity. The nurse is the
,coordinator of care, and collaborating with the dietitian would result in
planning the best meals for the patient. The respiratory therapist can be
consulted when a patient has issues with the respiratory system. Case
management can be consulted when the patient has a discharge need. A
chaplain can be consulted when the patient has a spiritual need.
3. The nurse is caring for a patient with a Stage II pressure ulcer and has
assigned a nursing diagnosis of Risk for infection. The patient is unconscious
and bedridden. The nurse is completing the plan of care and is writing goals
for the patient. Which is the best goal for this patient?
a. The patient will state what to look for with regard to an infection.
b. The patient’s family will demonstrate
specific care of the wound site. The
patient’s family members will wash
their hands when visiting the
c. patient.
The patient will remain free of odorous or purulent drainage from the
d. wound.
ANS: D
Because the patient has an open wound and the skin is no longer intact to
protect the tissue, the patient is at increased risk for infection. The nurse will
be assessing the patient for signs and symptoms of infection, including an
increase in temperature, an increase in white count, and odorous and
purulent drainage from the wound. The patient is unconscious and is unable
to communicate the signs and symptoms of infection. It is important for the
patient’s family to be able to demonstrate how to care for the wound and
wash their hands, but these statements are not goals or outcomes for this
nursing diagnosis.
4. The nurse is caring for a group of patients. Which task can the nurse
delegate to the nursing assistive personnel?
a. Assessing a surgical patient for risk of pressure ulcers
b. Applying an elastic bandage to a medical-surgical patient
c. Treating a pressure ulcer on the buttocks of a medical patient
d. Implementing negative-pressure wound therapy on a stable patient 191
, ANS: B
Applying an elastic bandage to a medical-surgical patient can be delegated to
the nursing assistive personnel (NAP). Assessing pressure ulcer risk, treating a
pressure ulcer, and implementing negative-pressure wound therapy cannot be
delegated to an NAP.
5. The nurse is performing a moist-to-dry dressing. The nurse has
prepared the supplies, solution, and removed the old dressing. In which
order will the nurse implement the steps, starting with the first one?
1. Apply sterile gloves.
2. Cover and secure topper dressing.
3. Assess wound and surrounding skin.
4. Moisten gauze with prescribed solution.
5. Gently wring out excess solution and unfold.
6. Loosely pack until all wound surfaces are in contact with gauze.
a. 4, 3, 1, 5, 6, 2
b. 1, 3, 4, 5, 6, 2
c. 4, 1, 3, 5, 6, 2
d. 1, 4, 3, 5, 6, 2
ANS: B
The steps for a moist-to-dry dressing are as follows: (1) Apply sterile gloves;
(2) assess appearance of surrounding skin; (3) moisten gauze with prescribed
solution. (4) Gently wring out excess solution and unfold; apply gauze as
single layer directly onto wound surface. (5) If wound is deep, gently pack
dressing into wound base by hand until all wound surfaces are in contact with
gauze; (6) cover with sterile dry gauze and secure topper dressing.
36. The nurse is caring for a patient who has suffered a stroke and has
residual mobility problems. The patient is at risk for skin impairment. Which
initial actions should the nurse take to decrease this risk?
a. Use gentle cleansers, and thoroughly dry the skin.
191
A+
1. The nurse is caring for a patient who is immobile. The nurse wants to
decrease the formation of pressure ulcers. Which action will the nurse take
first?
a. Offer favorite fluids.
b. Turn the patient every 2 hours.
c. Determine the patient’s risk factors.
d. Encourage increased quantities of carbohydrates and fats.
ANS: C
The first step in prevention is to assess the patient’s risk factors for pressure
ulcer development. When a patient is immobile, the major risk to the skin is the
formation of pressure ulcers. Nursing interventions focus on prevention.
Offering favorite fluids, turning, and increasing carbohydrates and fats are not
the first steps.
Determining risk factors is first so interventions can be implemented to reduce
or eliminate those risk factors.
2. The medical-surgical acute care patient has received a nursing diagnosis
of Impaired skin integrity. Which health care team member will the nurse
consult?
a. Respiratory therapist
b. Registered dietitian
c. Case manager
d. Chaplain
ANS: B
Refer patients with pressure ulcers to the dietitian for early intervention for 191
nutritional problems. Adequate calories, protein, vitamins, and minerals
promote wound healing for the impaired skin integrity. The nurse is the
,coordinator of care, and collaborating with the dietitian would result in
planning the best meals for the patient. The respiratory therapist can be
consulted when a patient has issues with the respiratory system. Case
management can be consulted when the patient has a discharge need. A
chaplain can be consulted when the patient has a spiritual need.
3. The nurse is caring for a patient with a Stage II pressure ulcer and has
assigned a nursing diagnosis of Risk for infection. The patient is unconscious
and bedridden. The nurse is completing the plan of care and is writing goals
for the patient. Which is the best goal for this patient?
a. The patient will state what to look for with regard to an infection.
b. The patient’s family will demonstrate
specific care of the wound site. The
patient’s family members will wash
their hands when visiting the
c. patient.
The patient will remain free of odorous or purulent drainage from the
d. wound.
ANS: D
Because the patient has an open wound and the skin is no longer intact to
protect the tissue, the patient is at increased risk for infection. The nurse will
be assessing the patient for signs and symptoms of infection, including an
increase in temperature, an increase in white count, and odorous and
purulent drainage from the wound. The patient is unconscious and is unable
to communicate the signs and symptoms of infection. It is important for the
patient’s family to be able to demonstrate how to care for the wound and
wash their hands, but these statements are not goals or outcomes for this
nursing diagnosis.
4. The nurse is caring for a group of patients. Which task can the nurse
delegate to the nursing assistive personnel?
a. Assessing a surgical patient for risk of pressure ulcers
b. Applying an elastic bandage to a medical-surgical patient
c. Treating a pressure ulcer on the buttocks of a medical patient
d. Implementing negative-pressure wound therapy on a stable patient 191
, ANS: B
Applying an elastic bandage to a medical-surgical patient can be delegated to
the nursing assistive personnel (NAP). Assessing pressure ulcer risk, treating a
pressure ulcer, and implementing negative-pressure wound therapy cannot be
delegated to an NAP.
5. The nurse is performing a moist-to-dry dressing. The nurse has
prepared the supplies, solution, and removed the old dressing. In which
order will the nurse implement the steps, starting with the first one?
1. Apply sterile gloves.
2. Cover and secure topper dressing.
3. Assess wound and surrounding skin.
4. Moisten gauze with prescribed solution.
5. Gently wring out excess solution and unfold.
6. Loosely pack until all wound surfaces are in contact with gauze.
a. 4, 3, 1, 5, 6, 2
b. 1, 3, 4, 5, 6, 2
c. 4, 1, 3, 5, 6, 2
d. 1, 4, 3, 5, 6, 2
ANS: B
The steps for a moist-to-dry dressing are as follows: (1) Apply sterile gloves;
(2) assess appearance of surrounding skin; (3) moisten gauze with prescribed
solution. (4) Gently wring out excess solution and unfold; apply gauze as
single layer directly onto wound surface. (5) If wound is deep, gently pack
dressing into wound base by hand until all wound surfaces are in contact with
gauze; (6) cover with sterile dry gauze and secure topper dressing.
36. The nurse is caring for a patient who has suffered a stroke and has
residual mobility problems. The patient is at risk for skin impairment. Which
initial actions should the nurse take to decrease this risk?
a. Use gentle cleansers, and thoroughly dry the skin.
191
