Question

A nurse performing a right eye irrigation will position the patient:

Answer 1

Correct Answers:

Supine with the head tilted toward the right eye.

Rationale :

🟢 The nurse should position the client supine with the head tilted toward the affected (right) eye to ensure the irrigation solution flows away from the unaffected eye.

🟢 This position helps prevent contamination of the other eye and promotes effective drainage.

🟢 Tilting the head away or hyperextending can cause discomfort or improper irrigation.

🟢 Proper positioning supports client safety and comfort during eye irrigation.

🟢 This technique is critical to prevent injury and maximize treatment effectiveness.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 2

Correct Answers:

Empty the reservoir.

Rationale :

⚫ When the Jackson-Pratt drain reservoir is half full, it should be emptied to maintain negative pressure (suction) essential for proper drainage of blood and fluids.

⚫ Failure to empty the reservoir can result in backflow, impaired drainage, and increased risk of infection or hematoma.

⚫ Immediate emptying is necessary to maintain the functionality of the drainage system.

⚫ Removing the drain or delaying notification without emptying is inappropriate unless significant bleeding occurs.

⚫ Proper management promotes wound healing and prevents complications.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 3

Correct Answers:

Add normal saline to loosen it.

Rationale :

🔵 The nurse should add normal saline to moisten the old dressing that is stuck to the wound bed, allowing it to loosen gently without damaging healing tissue.

🔵 This intervention prevents trauma to new granulation tissue and reduces pain during dressing removal.

🔵 Using povidone-iodine or forcefully pulling the dressing risks delaying healing and causing tissue injury.

🔵 Leaving the old dressing in place and adding wet dressings can promote bacterial growth and infection.

🔵 Moistening with saline supports optimal wound care and client comfort.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 4

Correct Answers:

From the outer abdomen toward the wound.

Rationale :

🟠 When cleansing a wound, the nurse should clean from the cleanest area (outer abdomen) toward the contaminated area (wound) to avoid introducing bacteria into the wound bed.

🟠 This technique reduces the risk of infection by minimizing contamination.

🟠 Cleaning in a circular motion or directly over the wound can cause cross-contamination and trauma.

🟠 Following proper cleansing protocols is essential to promote healing and client safety.

🟠 Maintaining aseptic technique prevents healthcare-associated infections.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 5

Correct Answers:

Intact skin with localized erythema.

Rationale :

🟡 A stage 1 pressure injury is characterized by intact skin with localized redness (erythema) that does not blanch when pressure is applied.

🟡 This early sign indicates tissue damage without skin breakdown.

🟡 Full-thickness skin loss with visible fat or bone indicates more advanced stage 3 or 4 injuries.

🟡 Partial-thickness skin loss with red tissue corresponds to a stage 2 pressure injury.

🟡 Early identification and intervention at stage 1 can prevent progression to more severe injuries.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 6

Correct Answers:

Change gloves after removing the old dressing.

Rationale :

🟡 Changing gloves after removing the old dressing is essential to prevent cross-contamination and maintain sterile technique during the dressing change.

🟡 Wearing the same gloves increases the risk of introducing pathogens to the wound.

🟡 While patient cooperation and positioning are important, maintaining sterility is paramount.

🟡 Having a discard bag nearby facilitates efficient disposal but is secondary to infection control practices.

🟡 Minimizing talking is helpful but does not substitute proper aseptic technique.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 7

Correct Answers:

Assist the patient in a supine position.

Rationale :

🔵 If the patient reports a sensation that “something let go,” the nurse should immediately assist the patient to a supine position to reduce abdominal pressure and risk of injury.

🔵 This position helps stabilize the abdomen and prevents strain on any possible wound dehiscence.

🔵 Applying an abdominal binder or seating the patient is secondary to ensuring immediate safety.

🔵 Panting can reduce abdominal pressure but first priority is positioning to avoid further damage.

🔵 Prompt positioning supports patient safety and allows for further assessment.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 8

Correct Answers:

Drawing the wound edges together by negative pressure.

Rationale :

🟠 Vacuum-assisted closure (VAC) devices support wound healing by applying negative pressure to draw wound edges together.

🟠 This suction promotes increased blood flow, reduced edema, and stimulation of granulation tissue.

🟠 VAC does not directly strengthen wound walls or create occlusive covers.

🟠 It helps reduce bacterial colonization indirectly by promoting wound healing.

🟠 Understanding VAC mechanics guides appropriate wound care choices.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 9

Correct Answers:

Dilating the blood vessels.

Rationale :

🟣 Moist heat causes vasodilation, which increases blood flow to the treated area.

🟣 Increased circulation aids in tissue repair, muscle relaxation, and pain relief.

🟣 Moist heat does not numb the area or constrict vessels; it promotes fluid movement but does not “draw” fluid to the site.

🟣 Proper use of moist heat facilitates healing and comfort.

🟣 Nurses must educate clients on safe application to avoid burns.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 10

Correct Answers:

Apply oxygen at 2L/min via nasal cannula.

Rationale :

⚫ During the initial inflammatory phase of wound healing, adequate oxygen delivery is critical to support cell metabolism and tissue repair.

⚫ Oxygen therapy enhances collagen synthesis and immune function in the wound area.

⚫ Leaving wounds open to air can increase infection risk.

⚫ Corticosteroids impair healing by suppressing inflammation and are generally avoided.

⚫ Mechanical debridement is a later intervention, not initial care.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

ATI PN Custom Fundamentals CH38 Exam

No.

1 :
A nurse performing a right eye irrigation will position the patient:

2 :
While assessing the client's abdomen, you note that the Jackson-Pratt drain's reservoir is expanded and half full of blood. Which is the appropriate action for you to take at this time?

3 :
The nurse changing a wet to dry normal saline dressing for a patient with an ulcer on the heel finds that the old dressing is stuck to the wound bed. The nurse's most beneficial intervention would be to:

4 :
The nurse is performing a dry sterile dressing change for an abdominal wound. The nurse should use a swab to clean:

5 :
A nurse is collecting data on a client who has a stage 1 pressure injury. Which of the following findings should the nurse expect?

6 :
When preparing to change a sterile dressing over an incision, it is most important to remember to:

7 :
A nurse is ambulating a patient in the hall a few days after abdominal surgery, and the patient says, "I think something just let go.”. The initial intervention by the nurse should be to:

8 :
The nurse clarifies that a vacuum-assisted closure supports healing of a wound by:

9 :
Moist heat has the physiological effect of:

10 :
A nurse is planning care for a client who has multiple wounds. During the initial stage of wound healing, which of the following should the nurse include in the plan of care?

Connect With Us

ATI PN Custom Fundamentals CH38 Exam

No.

1 : A nurse performing a right eye irrigation will position the patient:

2 : While assessing the client's abdomen, you note that the Jackson-Pratt drain's reservoir is expanded and half full of blood. Which is the appropriate action for you to take at this time?

3 : The nurse changing a wet to dry normal saline dressing for a patient with an ulcer on the heel finds that the old dressing is stuck to the wound bed. The nurse's most beneficial intervention would be to:

4 : The nurse is performing a dry sterile dressing change for an abdominal wound. The nurse should use a swab to clean:

5 : A nurse is collecting data on a client who has a stage 1 pressure injury. Which of the following findings should the nurse expect?

6 : When preparing to change a sterile dressing over an incision, it is most important to remember to:

7 : A nurse is ambulating a patient in the hall a few days after abdominal surgery, and the patient says, "I think something just let go.”. The initial intervention by the nurse should be to:

8 : The nurse clarifies that a vacuum-assisted closure supports healing of a wound by:

9 : Moist heat has the physiological effect of:

10 : A nurse is planning care for a client who has multiple wounds. During the initial stage of wound healing, which of the following should the nurse include in the plan of care?

1 :
A nurse performing a right eye irrigation will position the patient:

2 :
While assessing the client's abdomen, you note that the Jackson-Pratt drain's reservoir is expanded and half full of blood. Which is the appropriate action for you to take at this time?

3 :
The nurse changing a wet to dry normal saline dressing for a patient with an ulcer on the heel finds that the old dressing is stuck to the wound bed. The nurse's most beneficial intervention would be to:

4 :
The nurse is performing a dry sterile dressing change for an abdominal wound. The nurse should use a swab to clean:

5 :
A nurse is collecting data on a client who has a stage 1 pressure injury. Which of the following findings should the nurse expect?

6 :
When preparing to change a sterile dressing over an incision, it is most important to remember to:

7 :
A nurse is ambulating a patient in the hall a few days after abdominal surgery, and the patient says, "I think something just let go.”. The initial intervention by the nurse should be to:

8 :
The nurse clarifies that a vacuum-assisted closure supports healing of a wound by:

9 :
Moist heat has the physiological effect of:

10 :
A nurse is planning care for a client who has multiple wounds. During the initial stage of wound healing, which of the following should the nurse include in the plan of care?