ATI RN
RN-ATI-Fundamentals-of-Nursing-2023-2024 Questions
Extract:
Question 1 of 5
A nurse is caring for a client who is immobilized. Which of the following interventions is appropriate to prevent contracture?
Correct Answer: D
Rationale: The correct answer is D: Apply an orthotic to the client's foot. Contractures are a common complication in immobilized clients, where muscles and tendons shorten and tighten due to lack of movement. Applying an orthotic to the foot helps maintain proper alignment and prevents the foot from being in a fixed position, thus reducing the risk of contractures. Positioning a pillow under the client's knees (
A) may help with comfort but does not directly prevent contractures. Placing a towel roll under the client's neck (
B) is unrelated to preventing contractures in the lower extremities. Aligning a trochanter wedge between the client's legs (
C) is more for hip alignment and may not directly prevent contractures in the foot.
Question 2 of 5
A nurse is caring for a client who is experiencing expressive aphasia and right hemiparesis following a stroke. Which of the following actions by the nurse best promotes communication among staff caring for the client?
Correct Answer: D
Rationale: The correct answer is D: Having interdisciplinary team meetings for the client on a regular basis. This promotes communication among staff by ensuring that all team members involved in the client's care are updated on the client's condition, progress, and treatment plan. It allows for collaboration and coordination of care, leading to better outcomes for the client. Posting swallowing precautions (
A) only addresses one aspect of care and does not promote overall communication among staff. Noting changes in the treatment plan (
B) and recording progress in nurses' notes (
C) are essential but do not facilitate direct communication among staff. Interdisciplinary team meetings (
D) involve direct communication, discussion, and collaboration among team members, making it the best option.
Question 3 of 5
A nurse has just received change-of-shift report for four clients. Which of the following clients should the nurse assess first?
Correct Answer: C
Rationale: The nurse should assess client C first because low blood glucose levels can lead to serious complications if not addressed promptly. Hypoglycemia can result in altered mental status, seizures, and even coma. Assessing and addressing this client's low blood glucose level is a priority to prevent further deterioration.
Clients A, B, and D do not have immediate life-threatening conditions that require urgent assessment compared to client C. Client A, scheduled for a procedure in 1 hr, can be assessed after client C. Client B, who received pain medication 30 min ago, would have some time before needing reassessment. Client D, with 100 mL of fluid remaining in the IV bag, can also wait as long as there is no indication of the client being dehydrated or in need of immediate intervention.
Question 4 of 5
A nurse is performing postmortem care for a recently deceased client prior to the client's family viewing. Which of the following actions should the nurse take?
Correct Answer: B
Rationale: The correct answer is B: Hold the client's eyes shut for a few seconds. This action is appropriate because it helps create a peaceful appearance for the deceased client, providing a more dignified and comforting view for the family during the viewing. Holding the eyes shut is a common practice to maintain a natural appearance and show respect for the deceased.
Crossing the client's arms (
Choice
A) is not necessary and may not be culturally appropriate for all families. Placing the client in a high-Fowler's position (
Choice
C) is not recommended as it may not be comfortable or appropriate for viewing. Removing the client's dentures (
Choice
D) is also unnecessary and may not be respectful to the deceased.
Question 5 of 5
A nurse is caring for a client who requires seclusion to prevent harm to others on the unit. Which of the following is an appropriate action for the nurse to take?
Correct Answer: A
Rationale: The correct answer is A because documenting the client's behavior before seclusion is essential for comprehensive care, ensuring accurate assessment, and treatment planning. This documentation provides crucial information for evaluating the effectiveness of seclusion, understanding triggers, and creating a safer environment. Assessing the client's behavior, offering fluids, or discussing inappropriate behavior are important but secondary to documenting behavior for legal, ethical, and continuity of care reasons. Monitoring behavior continuously is more effective than hourly assessments.