ATI FUNDAMENTALS PROCTORED EXAM
1. The nurse is caring for a patient with cognitive impairments. Which actions
will the nurse take during AM care?
... [Show More] (Select all that apply.)
a. Administer ordered analgesic 1 hour before bath time.
b. Increase the frequency of skin assessment.
c. Reduce triggers in the environment.
d. Keep the room temperature cool.
e. Be as quick as possible.
ANS: B, C
If a patient is physically dependent or cognitively impaired, increase the
frequency of skin assessment. Adapt your bathing procedures and the environment
to reduce the triggers. For example, administer any ordered analgesic 30 minutes
before a bath and be gentle in your approach. Keep the patient’s body as warm as
possible with warm towels and be sure the room temperature is comfortable.
2. The nurse is caring for a patient who has peripheral neuropathy. Which
clinical manifestations does the nurse expect to find upon assessment? (Select
all that apply.)
a. Abnormal gait
b. Foot deformities
c. Absent or decreased pedal pulses
d. Muscle wasting of lower extremities
e. Decreased hair growth on legs and feet
ANS: A, B, D
A patient with peripheral neuropathy has muscle wasting of lower extremities, foot
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deformities, and abnormal gait. A patient with vascular insufficiency will have
decreased hair growth on legs and feet, absent or decreased pulses, and thickened
nails.
3. A nurse is providing hygiene care to a bariatric patient using chlorhexidine
gluconate (CHG) wipes. Which actions will the nurse take? (Select all that
apply.)
a. Do not rinse.
b. Clean under breasts.
c. Inform that the skin will feel sticky.
d. Dry thoroughly between skin folds.
e. Use two wipes for each area of the body.
ANS: A, B, C
CHG wipes are easy to use and accessible for older patients and bariatric patients,
offering a no-rinse or
-drying procedure. For a bariatric patient or a patient who is diaphoretic, provide
special attention to body areas such as beneath the woman’s breasts, in the groin,
skin folds, and perineal area, where moisture collects and irritates skin surfaces.
Use wipes as directed on package—one wipe per each area of the body. CHG can
leave the skin feeling sticky. If patients complain about its use, you need to
explain their vulnerability to infection and how CHG helps reduce occurrence of
health care–associated infection.
4. Which patients will the nurse determine are in need of perineal care? (Select
all that apply.)
a. A patient with rectal and genital surgical dressings
b. A patient with urinary and fecal incontinence
c. A circumcised male who is ambulatory
d. A patient who has an indwelling catheter
e. A bariatric patient
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ANS: A, B, D, E
Patients most in need of perineal care include those at greatest risk for acquiring
an infection (e.g., uncircumcised males, patients who have indwelling urinary
catheters, or those who are recovering from rectal or genital surgery or childbirth).
A patient with urinary and bowel incontinence needs perineal cleaning with each
episode of soiling. Bariatric patients need special attention to body areas such as
skin folds and the perineal area. In addition, women who are having a menstrual
period require perineal care. Circumcised males are not at high risk for acquiring
infection, and ambulatory patients can usually provide perineal self-care. [Show Less]