ATI Leadership Proctored Exam
ATI LEADERSHIP PROCTORED EXAM
1. 1. A nurse is caring for a postoperative patient. Which finding will alert
the
... [Show More] nurse to a potential wound dehiscence?
a. Protrusion of visceral organs through a wound opening
b. Chronic drainage of fluid through the incision site
c. Report by patient that something has given way
d. Drainage that is odorous and purulent
ANS: C
Patients often report feeling as though something has given way with dehiscence. Dehiscence occurs when an incision fails to heal properly and the layers of skin and tissue separate. It involves abdominal surgical wounds and occurs after a sudden strain such as coughing, vomiting, or sitting up in bed. Evisceration is seen when vital organs protrude through a wound opening. When there is an increase in serosanguineous drainage from a wound in the first few days after surgery, be alert for the potential for dehiscence. Infection is characterized by drainage that is odorous and purulent.
2. A patient has developed a pressure ulcer. Which laboratory data will be important
for the nurse to check?
a. Vitamin E
b. Potassium
c. Albumin
d. Sodium
ANS: C
Normal wound healing requires proper nutrition. Serum proteins are biochemical indicators of malnutrition, and serum albumin is probably the most frequently measured of these parameters. The best measurement of nutritional status is prealbumin because it reflects not only what the patient has ingested but also what the body has absorbed, digested, and metabolized. Zinc and copper are the minerals important for wound healing, not potassium and sodium. Vitamins A and C are important for wound healing, not vitamin E.
3. A nurse is caring for a patient with a wound. Which assessment data will be
most important for the nurse to gather with regard to wound healing?
a. Muscular strength assessment
b. Pulse oximetry assessment
c. Sensation assessment
d. Sleep assessment
ANS: B
Oxygen fuels the cellular functions essential to the healing process; the ability to perfuse tissues with adequate amounts of oxygenated blood is critical in wound healing. Pulse oximetry measures the oxygen saturation of blood. Assessment of muscular strength and sensation, although useful for fitness and mobility testing, does not provide any data with regard to wound healing. Sleep, although important for rest and for integration of learning and restoration of cognitive function, does not provide any data with regard to wound healing. [Show Less]