ATI RN
ATI RN Fundamentals 2019 II Questions
Question 1 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 2 of 5
A nurse is providing teaching to a client who is at risk for thrombus formation. Which of the following statements made by the client indicates an understanding of the teaching?
Correct Answer: C
Rationale: The correct answer is C: "I should limit the time that I spend sitting in a chair." This statement indicates an understanding of the teaching because prolonged sitting can increase the risk of thrombus formation. By limiting sitting time, the client can promote circulation and reduce the risk of blood clots.
A: Keeping legs crossed while sitting can actually impede circulation and increase the risk of thrombus formation.
B: Massaging legs when they hurt may provide temporary relief but does not address the root cause of thrombus formation.
D: Performing leg exercises once every 4 hours is beneficial, but it is not as effective as limiting sitting time to prevent thrombus formation.
Question 3 of 5
A nurse is documenting client care. Which of the following abbreviations should the nurse use?
Correct Answer: C
Rationale: The correct answer is C: SQ for subcutaneous. This abbreviation is widely accepted and understood in healthcare settings for documenting subcutaneous injections. It is important for nurses to use standardized, clear abbreviations to prevent misinterpretation and ensure accurate communication.
Choice A (SS for sliding scale) is ambiguous and could be misinterpreted.
Choice B (OJ for orange juice) is non-standard and may lead to confusion.
Choice D (BRP for bathroom privileges) is not appropriate for documenting care. Nurses should always prioritize clarity and accuracy in their documentation to promote patient safety and effective communication.
Question 4 of 5
A nurse is planning care for a client who is concerned about her tobacco smoking habits and is in the contemplation stage of health behavior change. Which of the following actions should the nurse plan to take during this stage?
Correct Answer: D
Rationale: The correct answer is D: Present information about the benefits of quitting smoking. During the contemplation stage of health behavior change, the client is considering making a change but may still have ambivalence. Providing information about the benefits of quitting smoking can help the client explore the advantages of changing their behavior. This can help increase the client's motivation and readiness to move towards action.
A: Recommend small changes for the client to make to change her behavior over time - This may be more suitable for the preparation or action stages, not contemplation.
B: Assist the client in setting goals to make the change - Goal-setting is more appropriate for the preparation or action stages.
C: Develop a plan for the client to integrate the change into her lifestyle - Planning typically occurs in the preparation stage when the client is ready to take action.
Question 5 of 5
A nurse is caring for a client who is receiving continuous enteral feeding via NG tube. Which of the following is an unexpected finding?
Correct Answer: D
Rationale: The correct answer is D: A gastric residual of 300 mL at the end of the shift. This finding is unexpected because a high gastric residual volume may indicate delayed gastric emptying or intolerance to enteral feeding, which can lead to complications such as aspiration or malnutrition. A weight gain (choice
A) is expected due to caloric intake. Blood glucose of 110 mg/dL (choice
B) is within normal range. Diarrhea once (choice
C) can occur with enteral feeding but is not unexpected. In summary, a high gastric residual volume is concerning and requires further assessment and intervention.