ATI RN
ATI RN Fundamentals 2023 Questions
Extract:
Question 1 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: B
Rationale: The correct answer is B: Help the client lie on the floor. This is the first action to take during a seizure to prevent injury. By lowering the client to the floor, the risk of falling and hitting objects is minimized, ensuring safety. Turning the client onto their side (choice
A) can be done after they are on the floor to prevent aspiration. Loosening clothing (choice
C) and moving items away (choice
D) are important but secondary to ensuring the client is on the ground.
Question 2 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?
Correct Answer: A,C,D
Rationale: The correct actions are A, C, and D.
A: Assessing skin temperature and color before applying restraints helps prevent skin breakdown.
C: Ensuring the bed is in the lowest position reduces fall risk and injury.
D: Padding bony prominences prevents pressure injuries.
B: Attaching restraints to the bed rail can cause harm if the client moves.
E: Allowing three fingers under restraints is too loose and can lead to escape or injury.
Question 3 of 5
A nurse is teaching a client who has decreased mobility about passive range-of-motion exercises. Which of the following statements should the nurse make?
Correct Answer: C
Rationale: The correct answer is C: "I will repeat these movements 3 to 5 times." This is the appropriate statement because passive range-of-motion exercises should be repeated multiple times to maintain joint mobility without causing excessive stress on the joints. Option A is incorrect because moving the joints to the point of mild pain can cause discomfort and potential harm. Option B is incorrect as moving the joints quickly may lead to strain or injury. Option D is incorrect because passive range-of-motion exercises are usually performed multiple times throughout the day to prevent joint stiffness.
Question 4 of 5
A nurse is caring for a client who has a colostomy. Which of the following actions should the nurse take?
Correct Answer: C
Rationale: The correct answer is C: Ensure the pouch is 0.32 cm (1/8 in) larger than the stoma. This is important to allow room for stoma swelling and prevent irritation.
Choice A is incorrect because rubbing the peristomal skin dry can cause skin breakdown.
Choice B is incorrect as colostomy pouches should be changed based on individual needs, not a set time frame.
Choice D is incorrect as the skin barrier should be applied to dry skin to ensure proper adhesion.
Question 5 of 5
A nurse is planning to change a client's tracheostomy ties. Which of the following actions should the nurse take?
Correct Answer: D
Rationale:
Correct Answer: D
Rationale: Cutting the old ties after securing the new ties ensures that the client's airway remains stable throughout the procedure. If the old ties are cut before securing the new ties, there is a risk of accidental decannulation, leading to potential airway compromise. This step-by-step approach prioritizes patient safety and prevents unnecessary risks during the tracheostomy tie change.
Summary:
A: Allowing space for three fingers under the ties is important for proper fit but not the immediate action needed during the tie change.
B: Using a quick-release knot may be helpful for easy removal in emergencies but is not the primary concern during the tie change.
C: Extending the client's neck may help with visualization but is not essential for securing the ties.
D: Cutting the old ties after securing the new ties is the correct action to maintain airway stability.
E, F, G: No information provided.