ATI RN
ATI RN Fundamentals 2023 Exam 5 Questions
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?
Correct Answer: B
Rationale: Electrical wires secured to baseboards are generally not considered a significant fall risk. Properly secured wires reduce the likelihood of tripping hazards compared to loose or exposed wires.
Therefore, this is not a primary concern for fall risk. Taking antihypertensive medication can increase the risk of falls, especially in older adults. These medications can cause orthostatic hypotension, a condition where blood pressure drops significantly upon standing, leading to dizziness and an increased risk of falling. This makes it a critical factor to consider in fall risk assessments. Wearing rubber-sole shoes is typically recommended to prevent falls because they provide good traction and reduce the risk of slipping. However, if the soles are too thick or bulky, they can catch on carpets or other surfaces, potentially causing trips. Generally, rubber-sole shoes are considered safer than other types of footwear. A visual acuity of 20/40 indicates some level of visual impairment, but it is not severe. While reduced visual acuity can contribute to fall risk, it is not as significant as the risk posed by medications that affect blood pressure. Visual impairments should still be addressed, but they are not the most immediate concern in this context.
Question 2 of 5
A nurse is caring for a client who has dysphagia. When assisting the client during breakfast, which of the following actions by the client indicates the nurse should intervene?
Correct Answer: B
Rationale: Adjusting the head of the bed to 90° is a recommended practice for clients with dysphagia. This position helps facilitate swallowing and reduces the risk of aspiration by using gravity to assist the passage of food and liquids from the mouth to the stomach. Drinking thickened juice with a straw is not recommended for clients with dysphagia. Using a straw can increase the speed and force with which liquids enter the mouth, making it harder to control the swallow and increasing the risk of aspiration. Thickened liquids are designed to move more slowly, giving the client more control over swallowing, but using a straw negates this benefit. Taking frequent breaks while eating is a good practice for clients with dysphagia. It allows them to chew and swallow food thoroughly, reducing the risk of choking and aspiration. This practice also helps prevent fatigue, which can impair swallowing function. Tucking the chin when swallowing, also known as the chin-tuck maneuver, is a common technique used to help clients with dysphagia. This action helps protect the airway by narrowing the space and reducing the risk of aspiration.
Question 3 of 5
A nurse is performing an eye assessment for a newly admitted client. Which of the following findings should the nurse expect?
Correct Answer: A
Rationale: Eyelashes that curl slightly outward are a normal finding in an eye assessment. This natural curl helps protect the eyes from debris and sweat, and it also aids in the distribution of tears across the eye surface. Eyelashes that curl outward are typical and expected in a healthy individual. Corneas with an opaque appearance are not a normal finding. The cornea should be clear and transparent, allowing light to pass through to the retina. An opaque cornea can indicate various conditions such as corneal edema, scarring, or infection.
Therefore, this finding would be abnormal and warrant further investigation. Eyelids that blink involuntarily 30 to 35 times per minute are not within the normal range. The average blink rate for a healthy adult is approximately 15 to 20 times per minute. A significantly higher blink rate could indicate an underlying condition such as dry eye syndrome, blepharospasm, or other neurological issues. Pupils that are 8 to 9 mm in diameter are abnormally large. The normal pupil size ranges from 2 to 4 mm in bright light and 4 to 8 mm in dim light. Pupils that are consistently larger than this range could indicate a condition such as mydriasis, which can be caused by various factors including medications, trauma, or neurological disorders.
Question 4 of 5
A nurse is preparing to transfer a client to the radiology department using a wheelchair. Which of the following actions should the nurse take?
Correct Answer: D
Rationale: Leaving a transfer belt in place until the client returns from radiology is not recommended. The transfer belt is used to assist in moving the client safely, but it should be removed once the client is securely seated in the wheelchair to prevent discomfort or potential injury. Positioning the client so their weight is shifted forward is not a standard practice for transferring a client to a wheelchair. Proper positioning involves ensuring the client is seated comfortably and securely, with their weight evenly distributed to prevent falls or injuries. Lowering the footplates before transferring the client from the bed is incorrect. The footplates should be raised to allow the client to safely transfer from the bed to the wheelchair without tripping or getting their feet caught. Backing the wheelchair into the elevator is the correct action. This ensures that the client enters the elevator facing forward, which is safer and more comfortable for the client. It also allows the nurse to maintain better control of the wheelchair during the transition.
Question 5 of 5
A nurse is providing teaching to a client about colorectal cancer prevention guidelines. Which of the following recommendations should the nurse include?
Correct Answer: C
Rationale: The recommendation for fecal occult blood tests (FOBT) is typically to have them annually, not every 2 years. Regular screening is crucial for early detection of colorectal cancer. The American Cancer Society suggests that people aged 45 and older should have an FOBT every year. This test helps detect hidden blood in the stool, which can be an early sign of cancer. Dietary fiber is actually beneficial in reducing the risk of colorectal cancer. High-fiber diets, rich in fruits, vegetables, and whole grains, are associated with a lower risk of developing colorectal cancer. Fiber helps in maintaining a healthy digestive system and can aid in the prevention of cancer by promoting regular bowel movements and reducing the time that potential carcinogens stay in the colon. Reducing the intake of red meats is a well-supported recommendation for lowering the risk of colorectal cancer. Studies have shown that high consumption of red and processed meats is linked to an increased risk of colorectal cancer. Reducing the intake of these meats and opting for healthier protein sources like fish, poultry, and plant-based proteins can help lower this risk. The standard recommendation for colonoscopy screening is every 10 years for individuals at average risk, starting at age 45. More frequent colonoscopies, such as every 3 years, are generally reserved for those with higher risk factors, such as a family history of colorectal cancer or the presence of polyps. Regular colonoscopy screenings are vital for detecting and removing polyps before they can develop into cancer.