ATI RN
ATI RN Fundamentals Updated 2023 Exam Questions
Question 1 of 5
A nurse is performing postural drainage with percussion and vibration for a client who has cystic fibrosis. Which of the following actions should the nurse take?
Correct Answer: B
Rationale: The correct answer is B: Cover the area of percussion with a towel. This is important to prevent skin irritation or discomfort during the procedure. The towel acts as a barrier between the client's skin and the nurse's hand, reducing friction and protecting the skin. Performing percussion directly on the skin can cause redness, bruising, or discomfort, so covering the area with a towel is a standard practice to ensure the client's safety and comfort.
Choice A is incorrect because percussion should be performed over specific areas of the chest, not the lower back.
Choice C is incorrect as postural drainage should be scheduled before meals to prevent aspiration.
Choice D is incorrect as clients should exhale slowly and relax during vibration to promote airway clearance.
Question 2 of 5
A nurse is teaching a group of newly licensed nurses about the Braden scale. Which of the following responses by a newly licensed nurse indicates an understanding of the teaching?
Correct Answer: B
Rationale:
Correct
Answer: B - The scale measures six elements.
Rationale: The Braden scale is used to assess a patient's risk for developing pressure ulcers and consists of six elements: sensory perception, moisture, activity, mobility, nutrition, and friction/shear. Understanding this indicates knowledge of the scale's components.
Incorrect
Choices:
A: Each element has a range from one to five points - This is incorrect because the elements are not scored on a range from one to five.
C: The client's age is part of the measurement - Age is not a factor in the Braden scale assessment.
D: The higher the score, the higher the pressure injury risk - This is incorrect as a higher score on the Braden scale indicates a lower risk of pressure ulcers.
Question 3 of 5
A nurse is preparing a sterile field to assist with suturing a client's laceration. Which of the following actions should the nurse plan to take?
Correct Answer: C
Rationale: The correct answer is C: Hold the bottle of sterile solution so that the label is facing the palm of the hand. This action is important to maintain the sterility of the solution. By holding the bottle with the label facing the palm, the nurse ensures that the solution does not come into contact with the outside of the bottle, which could introduce contaminants. This practice helps prevent the introduction of microorganisms into the sterile field, reducing the risk of infection for the client.
Incorrect options:
A: Applying sterile gloves before opening the bottle of sterile solution is not necessary for preparing the sterile field.
B: Placing the lid of the sterile solution bottle face down on the sterile drape can lead to contamination.
D: Pouring the sterile solution from a height of 20 cm (8 in) above the sterile bowl may create splashing and increase the risk of contamination.
Question 4 of 5
A nurse is assessing an older adult client. Which of the following findings should the nurse expect?
Correct Answer: B
Rationale: The correct answer is B: Decreased sense of balance. As people age, their sense of balance tends to decrease due to changes in vision, inner ear function, muscle strength, and joint flexibility. This can increase the risk of falls and injuries in older adults. The other choices are incorrect because heightened sense of pain (
A) is not a typical finding in older adults, increased nighttime sleeping (
C) may occur but it is not a universal finding, and nighttime urinary incontinence (
D) is common but not a definitive finding in all older adults.
Question 5 of 5
A nurse is discussing the stages of general adaptation syndrome with a newly licensed nurse. The nurse should identify that which of the following manifestations occurs during the alarm reaction stage?
Correct Answer: A
Rationale: During the alarm reaction stage of general adaptation syndrome, the body responds to stress by activating the fight-or-flight response. Dilated pupils occur as part of this response to enhance visual acuity and peripheral vision, preparing the individual for potential threats. This physiological change helps the person to be more aware and ready to react quickly in a stressful situation.
Choices B, C, and D are incorrect because physical exhaustion, bradycardia (slow heart rate), and depression are manifestations that are not typically associated with the alarm reaction stage. Physical exhaustion may occur in the exhaustion stage, bradycardia is not a typical response to stress, and depression is a psychological response that may occur in the resistance or exhaustion stages.