ATI RN
RN-ATI-Fundamentals-of-Nursing-2023-2024 Questions
Extract:
Question 1 of 5
A nurse has just received change-of-shift report for four clients. Which of the following clients should the nurse assess first?
Correct Answer: C
Rationale: The nurse should assess client C first because low blood glucose levels can lead to serious complications if not addressed promptly. Hypoglycemia can result in altered mental status, seizures, and even coma. Assessing and addressing this client's low blood glucose level is a priority to prevent further deterioration.
Clients A, B, and D do not have immediate life-threatening conditions that require urgent assessment compared to client C. Client A, scheduled for a procedure in 1 hr, can be assessed after client C. Client B, who received pain medication 30 min ago, would have some time before needing reassessment. Client D, with 100 mL of fluid remaining in the IV bag, can also wait as long as there is no indication of the client being dehydrated or in need of immediate intervention.
Question 2 of 5
A nurse is performing postmortem care for a recently deceased client prior to the client's family viewing. Which of the following actions should the nurse take?
Correct Answer: B
Rationale: The correct answer is B: Hold the client's eyes shut for a few seconds. This action is appropriate because it helps create a peaceful appearance for the deceased client, providing a more dignified and comforting view for the family during the viewing. Holding the eyes shut is a common practice to maintain a natural appearance and show respect for the deceased.
Crossing the client's arms (
Choice
A) is not necessary and may not be culturally appropriate for all families. Placing the client in a high-Fowler's position (
Choice
C) is not recommended as it may not be comfortable or appropriate for viewing. Removing the client's dentures (
Choice
D) is also unnecessary and may not be respectful to the deceased.
Question 3 of 5
A nurse is caring for a client who requires seclusion to prevent harm to others on the unit. Which of the following is an appropriate action for the nurse to take?
Correct Answer: A
Rationale: The correct answer is A because documenting the client's behavior before seclusion is essential for comprehensive care, ensuring accurate assessment, and treatment planning. This documentation provides crucial information for evaluating the effectiveness of seclusion, understanding triggers, and creating a safer environment. Assessing the client's behavior, offering fluids, or discussing inappropriate behavior are important but secondary to documenting behavior for legal, ethical, and continuity of care reasons. Monitoring behavior continuously is more effective than hourly assessments.
Question 4 of 5
A nurse is caring for a client who asks for information regarding organ donation. Which of the following responses should the nurse make?
Correct Answer: C
Rationale: The correct response is C: Your desire to be an organ donor must be documented in writing. This is the correct answer because in order for someone to become an organ donor, their wish to donate organs after death must be formally documented. This ensures that their wishes are legally binding and will be respected. It also helps healthcare providers and family members honor the individual's decision.
Other choices are incorrect because:
A: This response does not provide the necessary information about organ donation.
B: Age requirements for organ donation may vary by country or region, but it is not a universal rule.
D: Individuals can opt-out of being an organ donor at any time, so this statement is false.
E, F, G: No information given, so it is unclear if these choices are relevant to organ donation.
Question 5 of 5
A parish nurse is leading a support group for clients whose family members have committed suicide. Which of the following strategies should the nurse plan to use during the group session?
Correct Answer: B
Rationale: The correct answer is B: Initiate a discussion with clients about ways to cope with changes in family dynamics. This strategy is important in supporting clients dealing with the aftermath of a family member's suicide as it acknowledges the significant impact on family dynamics. It allows clients to explore and process the changes within the family system and develop coping mechanisms. This approach fosters open communication and mutual support within the group.
Choice A is incorrect because grief is a highly individualized process and establishing a timeline may not be helpful or realistic for everyone.
Choice C is incorrect as it may inadvertently place blame on the deceased and lead to feelings of guilt among clients.
Choice D is incorrect as it can hinder the healing process by suppressing valid emotions and preventing the group from exploring their feelings openly.