Extract:

Question 1 of 5

A home health nurse is performing a fall risk assessment for an older adult client. Which of the following findings should the nurse identify as a potential fall risk in the home?

A. The client has electrical wires secured to baseboards.B. The client wears rubber-sole shoes.C. The client's visual acuity is 20/40.D. The client takes an antihypertensive medication.

Correct Answer: D

Rationale: Antihypertensives (
D) can cause hypotension and dizziness, increasing fall risk. Secured wires (
A) and rubber soles (
B) reduce risk, and 20/40 vision (
C) is mildly impaired but less critical.

Question 2 of 5

A nurse is assessing a client's abdomen. In what order should the nurse complete the steps of the assessment? (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

A. Press deeply into the client's upper abdomen left of midline to detect aortic pulsation.B. Use fingertips to lightly depress the right lower quadrant of the client's abdomen.C. Systematically percuss the client's abdomen.D. Observe the contours of the client's abdomen using a penlightE. Determine the presence of bowel sounds by using the diaphragm of the stethoscope.

Correct Answer: D,E,C,B,A

Rationale: Abdominal assessment follows: inspection (
D) first to observe contours, auscultation (E) second for bowel sounds before palpation affects them, percussion (
C) third to assess sound quality, light palpation (
B) fourth for tenderness, and deep palpation (
A) last to avoid discomfort interference.

Question 3 of 5

A nurse is completing discharge teaching about ostomy care with a client who has a new stoma. Which of the following instructions should the nurse include in the teaching? (Select all that apply.)

A. Use povidone-iodine to clean around the stoma.'B. Cut the opening of the pouch 1/8 of an inch larger than the stoma.'C. Empty the ostomy pouch when it becomes one-third full of contents.'D. Place a piece of gauze over the stoma while changing the pouch.'E. Expect the stoma to turn a purple-blue color as it heals.'

Correct Answer: B,C,D

Rationale: Pouch opening 1/8 inch larger (
B) fits well, emptying at one-third (
C) prevents leaks, and gauze (
D) protects during changes. Povidone-iodine (
A) irritates, and purple-blue (E) signals poor blood flow, not healing.

Question 4 of 5

A nurse is assessing an older adult client's perception of sexuality. Which of the following statements made by the client indicates a need for intervention?

A. I do not have to worry about using protection now that I am in menopause.'B. I use lubricants to help prevent pain during sex.'C. I feel more self-conscious with how I look now that I am older.'D. I still think about having sex at my age?'

Correct Answer: A

Rationale: Not using protection post-menopause (
A) reflects a misconception; STIs remain a risk. Lubricants (
B), self-consciousness (
C), and interest in sex (
D) are normal.

Question 5 of 5

A nurse is teaching a client about logrolling while in bed. Which of the following information should the nurse include in the teaching?

A. Logrolling helps prevent friction when you are repositioned.'B. Logrolling will keep your spine in alignment.'C. You should keep your arms at your sides while logrolling'D. The head of your bed will be elevated prior to logrolls'

Correct Answer: B

Rationale: Logrolling (
B) maintains spinal alignment, critical for spinal injury clients. Friction (
A) is secondary, arms cross the chest (not sides,
C), and bed elevation (
D) isn’t required.

Nurselytic

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ATI RN Fundamentals 2023 Exam 3 Questions

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Question 1 of 5

Question 2 of 5

Question 3 of 5

Question 4 of 5

Question 5 of 5

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