ATI RN
ATI Fundamental Proctored Exam Study Guide 2024-2025 Questions
Extract:
Question 1 of 5
During the admission assessment, the nurse assesses the patient for fall risk. Which finding will alert the nurse to an increased risk for falls?
Correct Answer: B
Rationale: The correct answer is B: The patient takes a hypnotic. Patients taking hypnotic medications are at an increased risk for falls due to the sedative effects of these drugs, causing dizziness, impaired balance, and confusion. This increases the likelihood of accidents and falls.
Incorrect
Choices:
A: The patient is oriented. Being oriented does not necessarily indicate a decreased risk for falls.
C: The patient walks 2 miles a day. Regular exercise is beneficial for overall health but does not directly correlate with fall risk.
D: The patient recently became widowed. While emotional distress can affect a person's well-being, it does not directly indicate an increased risk for falls.
Question 2 of 5
A patient may need restraints. Which task can the nurse delegate to a nursing assistive personnel?
Correct Answer: D
Rationale: The correct answer is D: Applying the restraint. The rationale is that applying restraints is a task that can be safely delegated to nursing assistive personnel as it involves following specific instructions and does not require complex decision-making. Nursing assistive personnel can be trained to apply restraints safely under the supervision of a registered nurse.
A: Determining the need for restraints requires clinical judgment and assessment skills, which should be done by the registered nurse.
B: Assessing the patient's orientation involves critical thinking and interpretation of assessment findings, which is outside the scope of practice for nursing assistive personnel.
C: Obtaining an order for a restraint requires communication with the healthcare provider and understanding of legal and ethical implications, which should be done by the registered nurse.
Question 3 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 4 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 5 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.