ATI RN
Client Safety Questions
Question 1 of 5
The new graduate RN needs to have a preceptor assigned to him as he begins working in the pediatric clinic. The BEST person for this assignment would be
Correct Answer: B
Rationale: The correct answer is B, the staff RN with 3 years of experience who enjoys orienting new employees. This choice is the best because of the staff RN's combination of experience and willingness to mentor. The 3 years of experience indicate a good foundation of knowledge and skills, making them a suitable preceptor for the new graduate. Additionally, their enjoyment of orienting new employees suggests they have a positive attitude towards teaching and mentoring, which is crucial for a successful preceptor-preceptee relationship. A: The charge RN may be a natural leader and know policies, but that doesn't necessarily translate to being the best preceptor for a new graduate who needs guidance and support in clinical practice. C: The LPN may have extensive experience and knowledge of doctor's preferences, but the scope of practice and educational background differ from that of an RN, making them less suitable for preceptorship. D: The staff RN with 10 years of experience refusing to work with students is not an ideal
Question 2 of 5
When assessing visual acuity of the older adult, which visual finding is associated with aging?
Correct Answer: B
Rationale: The correct answer is B: Presbyopia. Presbyopia is a common age-related condition where the eye's lens loses flexibility, leading to difficulty focusing on close objects. Myopia (choice A), nearsightedness, is not specifically associated with aging. Strabismus (choice C), misalignment of the eyes, typically develops in childhood. Astigmatism (choice D), an irregular curvature of the eye's cornea or lens, can affect people of all ages, not just older adults. Presbyopia is the most relevant choice for visual changes associated with aging due to the natural aging process affecting the eye's ability to focus on close objects.
Question 3 of 5
Upon skin inspection of an older adult, the coccyx wound is noted to be intact, reddened, and non-blanchable. What is the best way to document the nurse's assessment finding?
Correct Answer: A
Rationale: The correct way to document the nurse's assessment finding of an intact, reddened, and non-blanchable coccyx wound in an older adult is as a stage I pressure injury. A stage I pressure injury is characterized by intact skin with non-blanchable redness. In this case, the skin is intact, showing the initial signs of tissue damage due to pressure. Stages II, III, and IV pressure injuries involve more severe damage to the skin and underlying tissues. Stage II involves partial-thickness skin loss, stage III involves full-thickness skin loss, and stage IV involves full-thickness skin loss with extensive tissue necrosis. Since the coccyx wound is only showing redness without any loss of skin integrity, it aligns with a stage I pressure injury. Choices B, C, and D are incorrect as they describe more advanced stages of pressure injuries with skin breakdown, which is not present in this case.
Question 4 of 5
A nursing student is caring for a 78-year-old patient with multiple sclerosis. The patient has had an indwelling Foley catheter in for 3 days. Eight hours ago the patient's temperature was 37.1° C (98.8° F). The student reports her recent assessment to the registered nurse (RN): the patient's temperature is 37.2° C (99° F); the Foley catheter is still in place, draining dark urine; and the patient is uncertain what time of day it is. From what the RN knows about presentation of symptoms in older adults, what should he recommend first?
Correct Answer: D
Rationale: The correct answer is D. The increase in the patient's temperature and dark urine could indicate a urinary tract infection (UTI), a common issue in older adults with indwelling catheters. The patient's confusion could be a sign of systemic infection. The RN should recommend a urine culture to confirm UTI and initiate appropriate treatment. A is incorrect because confusion in an older adult should not be dismissed without investigating the underlying cause. B is incorrect as increasing fluid intake may dilute the urine but does not address the potential infection. C is incorrect as the assessment findings are not normal and should not be ignored.
Question 5 of 5
A 71-year-old patient enters the emergency department after falling down stairs in the home. The nurse is conducting a fall history with the patient and his wife. They live in a one-level ranch home. He has had diabetes for over 15 years and experiences some numbness in his feet. He wears bifocal glasses. His blood pressure is stable at 130/70. The patient does not exercise regularly and states that he experiences weakness in his legs when climbing stairs. He is alert, oriented, and able to answer questions clearly. What are the fall risk factors for this patient? (Select all that apply.)
Correct Answer: A
Rationale: The correct answer is A: Impaired vision. The patient's bifocal glasses indicate vision impairment, which is a significant fall risk factor as it affects depth perception and balance. This is evident as the patient experiences weakness in his legs when climbing stairs, which could be due to the visual impairment affecting his ability to judge distance and steps. The other choices are incorrect: Residence design (B) is not a factor since they live in a one-level ranch home; Blood pressure (C) is stable and not a fall risk factor in this case; Leg weakness (D) is a symptom of the patient's diabetes and could contribute to falls but is not the primary risk factor in this scenario.