ATI Fundamentals 2023 Retake

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?

A. The hot water heater is set to 47°C (117°F).B. Grab bars are installed in the shower.C. Prescriptions are stored in a medication organizer.D. There is an area rug covering a tile floor.

Correct Answer: D

Rationale: An area rug (
D) risks falls in osteoporosis; it should be secured or removed. Low water temp (
A), grab bars (
B), and organizers (
C) enhance safety.

Question 2 of 5

A nurse is preparing to set up a sterile field. Which of the following actions should the nurse take?

A. Open the outermost flap of the sterile kit toward the body.B. Hold bottles of sterile solution with the label in the palm of the hand.C. Pour liquids into containers outside the sterile field.D. Place the sterile field at the level of the nurse's hips.

Correct Answer: B

Rationale: Holding bottles label-in-palm (
B) prevents drips contaminating the field. Flap toward body (
A) risks contamination, pouring outside (
C) breaks sterility, and hip level (
D) is too low (waist or above).

Question 3 of 5

A nurse is planning care for a client who has acute pain as a result of a pressure injury to the sacrum. Which of the following nonpharmacological interventions should the nurse include in the plan?

A. Loosen the client's bed linens.B. Massage the client's sacrum.C. Offer to play music in the client's room.D. Provide bright lights in the client's room.

Correct Answer: C

Rationale: Music (
C) distracts and relaxes, reducing pain perception. Loose linens (
A) don’t target pain, massaging (
B) worsens injury, and bright lights (
D) increase discomfort.

Question 4 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.)

A. Attach the client's restraints to the bed rail.B. Pad bony prominences before applying the restraints.C. Secure restraints to allow three fingers to slide under the restraints.D. Ensure that the client's bed is in the lowest position.E. Assess skin temperature and color before applying the restraints.

Correct Answer: B,D,E

Rationale: Padding (
B) prevents injury, lowest bed position (
D) reduces fall risk, and assessing skin (E) monitors circulation. Bed rails (
A) risk injury, and two fingers (not three,
C) ensure proper fit.

Question 5 of 5

A nurse is admitting a client who is at risk for falls to a medical-surgical unit. Which of the following actions should the nurse take?

A. Provide the client with a night light.B. Elevate full-length side rails on both sides of the client's bed.C. Place the bedside table 0.9 m (3 feet) away from the bed.D. Keep the client's room temperature at 18°C (64.4°F).

Correct Answer: A

Rationale: A night light (
A) reduces fall risk by aiding navigation. Full rails (
B) are restraints, distant tables (
C) hinder access, and temperature (
D) isn’t fall-related.

ATI Fundamentals 2023 Retake | Nurselytic

Nurselytic

ATI RN

ATI RN