ATI RN
ATI RN Fundamentals 2023 I Questions
Extract:
Question 1 of 5
A home health nurse is assessing the home environment of an older adult client who has osteoporosis. For which of the following findings should the nurse intervene?
Correct Answer: C
Rationale: The correct answer is C: There is an area rug covering a tile floor. Area rugs can pose a tripping hazard for older adults, especially those with osteoporosis who are at increased risk of falls and fractures. The uneven surface of the rug over the tile floor can lead to slips and falls, potentially causing serious injuries. The nurse should intervene by recommending the removal of the area rug to create a safer environment for the client.
Incorrect answers:
A: Grab bars in the shower are a safety measure to prevent falls, so this is a positive finding.
B: The hot water heater set at 47°C is within the recommended safe temperature range to prevent scalding, so no intervention is needed.
D: Storing prescriptions in a medication organizer promotes medication safety and organization, so this is not a concern.
Question 2 of 5
A nurse is preparing to provide tracheostomy care for a client. Which of the following actions should the nurse plan to take?
Correct Answer: C
Rationale: The correct answer is C: Secure the tracheostomy in place with a collar that has hook-and-loop fasteners. This is important to prevent accidental dislodgement of the tracheostomy tube. The collar provides stability and support to keep the tube in place. Cutting a gauze pad to place under the flanges (
A) is not necessary and may increase the risk of infection. Cleansing the skin with full-strength hydrogen peroxide (
B) can be irritating and damaging to the skin. Wearing clean gloves while cleaning the inner cannula (
D) is essential for infection control but is not directly related to securing the tracheostomy in place.
Question 3 of 5
A nurse is caring for a client who has a terminal illness. The client states, 'I am not giving up. I want as much treatment as possible.' Which of the following responses should the nurse make?
Correct Answer: D
Rationale: The correct answer is D: I will contact your provider to discuss your options. This response is appropriate because it demonstrates respect for the client's wishes while also ensuring that the client receives the necessary information to make informed decisions about their care. By contacting the provider, the nurse can facilitate a discussion about the available treatment options, potential benefits, risks, and expected outcomes. This empowers the client to make choices that align with their values and goals.
A: Enjoy the time you have and do the things you want to do - This response may come off as dismissive of the client's desire for treatment and does not address the need for a discussion with the healthcare provider.
B: Hospice care is the best thing for you at this time - While hospice care may be appropriate for some clients with terminal illnesses, it should not be assumed without a thorough discussion with the client and their healthcare provider.
C: You need to understand that you have very little time left - This response is blunt and
Question 4 of 5
A nurse is planning to administer insulin to a client who has type 1 diabetes mellitus, what action should the nurse perform first?
Correct Answer: C
Rationale: The correct answer is C: Verify the dose of insulin with another nurse once it is prepared. This is the first action the nurse should perform to ensure patient safety through a double-check process. It helps prevent medication errors by confirming the accuracy of the insulin dose before administration. Administering the insulin dose using a tuberculin syringe (
A) may be appropriate, but verifying the dose first is crucial. Using a filter needle when withdrawing medication from the multidose vial (
B) is not necessary for administering insulin. Mixing long-acting and rapid-acting insulin in one syringe (
D) is contraindicated as it may alter the pharmacokinetics of the insulin types.
Question 5 of 5
A nurse is planning care for a client who has a prescription for extremity restraints to both wrists. Which of the following actions should the nurse include in the plan of care? (Select all that apply.)
Correct Answer: A,B,D
Rationale:
Correct Answer: A, B, D
Rationale:
A: Ensuring the client’s bed is in the lowest position prevents falls and minimizes injury risk if the client tries to get out of bed.
B: Assessing skin temperature and color before applying restraints ensures proper circulation and skin integrity.
D: Padding bony prominences before applying restraints prevents pressure ulcers and discomfort for the client.
Summary:
C: Attaching the restraints to the bed rail can increase the risk of injury if the client moves around.
E: Allowing three fingers to slide under the restraints is incorrect as it can lead to improper fit and ineffective restraint.