ATI RN
ATI Fundamentals 2023 Retake Questions
Question 1 of 5
A nurse is assessing a client who has left-sided weakness following a stroke. Which of the following findings is the nurse's priority?
Correct Answer: B
Rationale: The correct answer is B: The client coughs frequently while eating. This is the priority finding because it indicates a risk of aspiration, which is a life-threatening complication post-stroke. Aspiration can lead to pneumonia and respiratory distress. Addressing this issue promptly is crucial to prevent further complications. The other choices are not as critical. A high blood pressure (option
A) can be managed with medication adjustments. Leaning to the left side (option
C) may be due to the weakness and can be addressed with positioning. Consuming only 25% of meals (option
D) is concerning but not as immediately life-threatening as the risk of aspiration.
Question 2 of 5
A nurse is preparing to perform an anthropometric assessment on a client. Which of the following client data should the nurse include?
Correct Answer: C
Rationale: The correct answer is C: Weight. Anthropometric assessment involves measuring body dimensions like weight, height, and body composition to evaluate a client's health status. Weight provides valuable information on nutritional status, hydration levels, and overall health. Level of orientation (
A) is related to cognitive function, not anthropometric assessment. Current pain level (
B) is important for pain management but not for anthropometric assessment. Respiratory rate (
D) is a vital sign and not typically part of anthropometric assessment. Weight is the most relevant data for this assessment.
Question 3 of 5
A nurse is caring for a client who is postoperative and is on bed rest. Which of the following actions should the nurse take to decrease the client's risk of developing a pressure injury?
Correct Answer: D
Rationale: The correct answer is D: Ensure the client's heels are not touching the mattress. This is crucial in preventing pressure injuries as pressure on the heels can lead to tissue damage. Elevating the heels off the bed reduces pressure and improves circulation. Repositioning every 4 hours (choice
A) is important but may not be enough to prevent heel pressure injuries. Raising the head of the bed (choice
B) is more for respiratory support and does not directly prevent pressure injuries. Massaging bony prominences (choice
C) can actually increase the risk of skin breakdown.
Question 4 of 5
A nurse is caring for an adolescent client who has full-thickness burns on their leg. The client expresses concern about their future. Which of the following is a therapeutic response by the nurse?
Correct Answer: C
Rationale: The correct answer is C, "You're concerned about what will happen when you leave the hospital?" This response shows empathetic listening, acknowledges the client's feelings, and opens the door for further discussion. Option A dismisses the client's feelings. Option B implies the client shouldn't be concerned. Option D minimizes the client's emotions and focuses solely on physical aspects.
Question 5 of 5
A nurse in a mental health clinic is caring for an older adult client who has depression and has stopped taking their medication. The client tells the nurse, 'I want to die now that my partner is gone.' Which of the following responses should the nurse make?
Correct Answer: B
Rationale: Answer B is correct because it directly addresses the client's statement about wanting to die, which indicates suicidal ideation. By asking if the client has thought about harming themselves, the nurse is assessing the client's risk of self-harm and can then take appropriate actions to ensure the client's safety.
Answer A is incorrect as it focuses on the medication issue rather than the client's immediate safety. Answer C is incorrect as it shifts the focus away from the client's suicidal thoughts. Answer D is also incorrect as it doesn't address the immediate risk of self-harm and instead suggests discussing the feelings with the provider without assessing the client's safety first.