ATI RN
ATI Fundamental Proctored Exam Study Guide 2024-2025 Questions
Extract:
Question 1 of 5
A patient has an ankle restraint applied. Upon assessment the nurse finds the toes a light blue color. Which action will the nurse take next?
Correct Answer: A
Rationale: The correct answer is A: Remove the restraint. The blue color in the toes indicates impaired circulation, possibly due to the ankle restraint being too tight. Removing the restraint will allow blood flow to return to the toes and prevent further complications such as tissue damage or necrosis.
Choice B is incorrect as it does not address the underlying circulation issue.
Choice C is not necessary unless there are other concerning neurological symptoms present.
Choice D is important for overall assessment but does not address the immediate issue of impaired circulation.
Question 2 of 5
The emergency department has been notified of a potential bioterrorism attack. Which action by the nurse is priority?
Correct Answer: B
Rationale: The correct answer is B: Manage all patients using standard precautions. This is the priority action because in a potential bioterrorism attack, protecting both patients and staff from exposure to any harmful agents is crucial. Standard precautions help prevent the spread of infections and ensure safety for everyone in the emergency department. Monitoring for specific symptoms (choice
A) is important but comes after ensuring immediate safety. Transporting patients quickly (choice
C) may increase the risk of spreading potential agents. Preparing for post-traumatic stress (choice
D) is important but not the priority in the initial response to a bioterrorism threat.
Question 3 of 5
The patient is confused, is trying to get out of bed, and is pulling at the intravenous infusion tubing. Which nursing diagnosis will the nurse add to the care plan?
Correct Answer: D
Rationale: The correct answer is D: Risk for injury. The patient's confusion and behavior of trying to get out of bed and pulling at the IV tubing indicate a potential risk for self-injury. Confusion can lead to falls or accidents, and pulling at the IV tubing can cause dislodgement leading to infection or inadequate medication delivery. The nurse's priority is to prevent harm to the patient.
Other choices are incorrect because:
A: Impaired home maintenance focuses on the patient's ability to maintain a safe and healthy home environment, not applicable in this acute care setting.
B: Deficient knowledge pertains to lack of understanding about a health condition or treatment, not relevant to the immediate safety concern.
C: Risk for poisoning does not align with the current scenario of potential physical harm due to the patient's confused behavior.
Question 4 of 5
A confused patient is restless and continues to try to remove the oxygen cannula and urinary catheter. What is the priority nursing diagnosis and intervention to implement for this patient?
Correct Answer: A
Rationale: The correct answer is A: Risk for injury: Check on patient every 15 minutes.
Rationale:
1. Priority: Safety of the patient is the top priority, as the patient is at risk for injury due to attempts to remove essential medical devices.
2. Regular monitoring: Checking on the patient every 15 minutes allows for timely intervention if the patient attempts to remove the oxygen cannula or urinary catheter.
3. Prevention of harm: By checking frequently, nurses can prevent potential harm such as hypoxia or catheter-related complications.
4. Immediate action: This intervention addresses the immediate safety concern and ensures the patient's well-being.
Incorrect choices:
B: Risk for suffocation: Placing a sign does not directly address the patient's behavior.
C: Disturbed body image: Patient's behavior is not related to body image concerns.
D: Deficient knowledge: Explaining the purpose does not address the immediate safety risk.
Question 5 of 5
The patient applies sequential compression devices after going to the bathroom. The nurse checks the patient's application of the devices and finds that they have been put on upside down. Which nursing diagnosis will the nurse add to the patient's plan of care?
Correct Answer: B
Rationale:
Correct
Answer: B - Deficient knowledge
Rationale: The nurse's assessment indicates that the patient lacks the knowledge to properly apply the sequential compression devices, leading to them being put on upside down. This nursing diagnosis reflects the patient's need for education on device application to prevent potential harm.
Summary of other choices:
A: Risk for falls - Not directly related to the incorrect application of sequential compression devices.
C: Risk for suffocation - Not relevant to the situation described.
D: Impaired physical mobility - Incorrect application of devices does not necessarily indicate impaired physical mobility.