ATI RN
ATI RN Fundamentals 2019 II Questions
Question 1 of 5
A nurse is implementing seizure precautions for a client who has a seizure disorder. Which of the following equipment should the nurse place at the client's bedside? (Select all that apply.)
Correct Answer: B,C,E
Rationale: The correct equipment to place at the client's bedside for seizure precautions includes oral suction equipment (
B) to clear the airway, supplemental oxygen supplies (
C) to ensure adequate oxygenation, and an oral airway (E) to maintain a patent airway during and after a seizure. Limb restraints (
A) are not recommended as they can cause injury and restrict movement. A blood glucose monitor (
D) is not directly related to seizure precautions.
Question 2 of 5
A charge nurse in a long-term care facility is preparing an educational program about delirium for newly hired nurses. Which of the following statements should the nurse plan to include?
Correct Answer: D
Rationale:
Rationale: The correct answer is D because delirium typically has an abrupt onset, manifesting as a sudden change in mental status. This is crucial for nurses to recognize promptly for appropriate intervention.
Choice A is incorrect as delirium can disrupt a client's sleep cycle.
Choice B is incorrect as delirium can alter a client's perception of their environment.
Choice C is incorrect as delirium often has a rapid progression, not a slow one.
Therefore, choice D is the most appropriate statement to include in the educational program.
Question 3 of 5
A nurse is delegating client care tasks to an assistive personnel. Which of the following tasks should the nurse delegate?
Correct Answer: B
Rationale:
Correct
Answer: B (Performing a simple dressing change)
Rationale:
1. Simple dressing changes are routine, non-invasive tasks that do not require advanced nursing skills.
2. Assistive personnel can be trained to perform dressing changes safely under the supervision of a nurse.
3. Delegating this task allows the nurse to focus on more complex care responsibilities.
4. Inserting an NG tube (
A) requires specialized training, evaluation of healing (
C) requires nursing judgment, and changing IV tubing (
D) involves potential complications if not done correctly.
Question 4 of 5
A nurse is providing teaching for a client who is scheduled for an allogeneic stem cell transplant. Which of the following information should the nurse include?
Correct Answer: C
Rationale: The correct answer is C: Your visitors will need to wear protective gowns. This is important because visitors can introduce infections to the immunocompromised client. The use of protective gowns helps prevent the transmission of pathogens.
A: Incorrect. Negative-airflow rooms are typically used for clients with airborne infections, not specifically for stem cell transplant clients.
B: Incorrect. Semi-private rooms may increase the risk of exposure to infections from other clients.
D: Incorrect. The client, not the visitor, should wear a mask to reduce the risk of infection transmission.
Overall, choice C is correct because it directly addresses the need for infection control measures to protect the client during the stem cell transplant process.
Question 5 of 5
A nurse is preparing to administer IV fluids to a client. The nurse notes sparks when plugging in the IV pump. Which of the following actions should the nurse take first?
Correct Answer: A
Rationale: The correct answer is A: Unplug the pump. This is the first action the nurse should take to ensure immediate safety. Sparks indicate an electrical issue that could lead to a potential hazard such as fire or electric shock. By unplugging the pump, the nurse eliminates the source of the sparks, preventing any further danger to the client or staff. Labeling the pump with a defective equipment sticker (
B) is not the priority as the immediate risk should be addressed first. Obtaining a replacement pump (
C) can be done after ensuring safety. Notifying the biomedical department (
D) can be the next step once the immediate danger is mitigated.