ATI RN
ATI RN Fundamentals 2023 I Questions
Extract:
Question 1 of 5
A charge nurse is observing a staff nurse performing a wound irrigation for a client who has a pressure injury. Which of the following actions by the staff nurse indicates an understanding of the procedure?
Correct Answer: B
Rationale: The correct answer is B because using a syringe with a catheter for wound irrigation allows for controlled and directed flow of the irrigation solution into the wound, ensuring effective cleansing and minimizing contamination. This method helps prevent trauma to the wound and surrounding tissues.
A: Using one pair of gloves for dressing removal and irrigation increases the risk of cross-contamination.
C: Administering an analgesic medication before irrigation is not a standard practice and does not demonstrate understanding of the procedure.
D: Refrigerating the solution before irrigation is unnecessary and may cause discomfort to the client.
In summary, choice B is correct as it aligns with best practices for wound irrigation, while the other choices do not demonstrate a proper understanding of the procedure.
Question 2 of 5
A nurse is reviewing the client’s medical record. Which of the following findings places the client at risk for heart disease? (Select all that apply.)
Correct Answer: A,B,C,E,F
Rationale: The correct answer includes family history, fasting glucose level, history of hyperlipidemia, hypertension, and cholesterol level. Family history is a non-modifiable risk factor for heart disease. Elevated fasting glucose indicates potential diabetes, a risk factor for heart disease. Hyperlipidemia contributes to plaque buildup in arteries. Hypertension strains the heart and blood vessels. Abnormal cholesterol levels can lead to atherosclerosis.
Choices D and G are not directly linked to heart disease risk.
Question 3 of 5
A nurse is assessing a client who is receiving a blood transfusion. The nurse notes lung crackles, hypoxia, and distended neck veins. Which of the following actions should the nurse take? (Select all that apply.)
Correct Answer: A,C,E
Rationale:
Correct Answer: A, C, E
Rationale:
A: Placing the client in high-Fowler's position helps improve oxygenation by maximizing lung expansion.
C: Administering oxygen is essential to improve oxygen levels and support respiratory function.
E: Stopping the transfusion is crucial as the client is showing signs of fluid overload, indicated by crackles and distended neck veins.
Summary of Incorrect
Choices:
B: Administering epinephrine is not indicated as the client's symptoms are related to fluid overload, not anaphylactic reaction.
D: Administering a diuretic is not the immediate priority as it won't address the acute respiratory distress caused by fluid overload.
Question 4 of 5
A nurse enters the room of a client who has a seizure disorder. The client is sitting in a chair and begins to experience a seizure. Which of the following actions should the nurse take first?
Correct Answer: D
Rationale: The correct action is to help the client lie on the floor first. This is crucial to prevent injury during a seizure as it provides a safe environment for the client. By lying on the floor, the client is protected from falling out of the chair, hitting their head, or sustaining other injuries. Moving items in the room away from the client, loosening clothing, and turning the client onto their side are important actions, but they should be done after ensuring the client is safely on the floor. These actions can be taken once the immediate risk of injury is minimized by having the client lie down.
Question 5 of 5
A nurse is caring for a client who is anxious about being admitted to a health care facility for the first time. Which of the following statements should the nurse make?
Correct Answer: A
Rationale: The correct answer is A: "We can discuss what you can expect during your stay." This statement acknowledges the client's anxiety, offers support, and provides reassurance by indicating a willingness to address their concerns. It opens the door for open communication and allows the nurse to provide information to help alleviate the client's anxiety.
Incorrect choices:
B: "Most people are scared their first time in a health care facility" - This statement generalizes the client's feelings and does not address their specific concerns.
C: "You have nothing to worry about. Everything will be fine" - This statement dismisses the client's feelings and does not offer any support or information.
D: "Why are you feeling scared about being in this facility?" - This question might come off as confrontational and may make the client feel defensive, rather than supported.