ATI RN
ATI RN Fundamentals 2023 II Questions
Extract:
Question 1 of 5
A nurse identifies a small fire in a client's room. After moving the client to safety, which of the following is the next action the nurse should take?
Correct Answer: B
Rationale: The correct answer is B: Activate the facility's fire alarm. This is the next action the nurse should take after ensuring the client's safety. Activating the fire alarm alerts other staff members and emergency services, allowing for a quicker and more coordinated response to the fire. Placing wet towels along the base of the door (choice
A) may help prevent smoke from entering the room but does not address the larger issue of alerting others to the fire. Directing a fire extinguisher at the fire (choice
C) should only be done if the nurse is trained to do so and it is safe. Turning off any electrical equipment (choice
D) may be necessary to prevent further hazards but does not take precedence over alerting others to the fire.
Question 2 of 5
A nurse is caring for a client who has a terminal illness. The client states, 'I am not giving up. I want as much treatment as possible.' Which of the following responses should the nurse make?
Correct Answer: D
Rationale: The correct answer is D: "I will contact your provider to discuss your options." This response honors the client's wishes for further treatment while also involving the healthcare provider to discuss available options. The nurse respects the client's autonomy and ensures that the provider is aware of the client's desires, allowing for a collaborative decision-making process.
Choice A is incorrect because hospice care may not align with the client's wishes for further treatment.
Choice B is incorrect as it may not be the nurse's role to predict or disclose the client's prognosis without the provider's input.
Choice C is incorrect as it assumes the client's desires without involving the provider.
In summary, choice D is the best response as it respects the client's wishes, involves the healthcare provider, and allows for a comprehensive discussion of treatment options.
Question 3 of 5
A charge nurse is observing a staff nurse performing a wound irrigation for a client who has a pressure injury. Which of the following actions by the staff nurse indicates an understanding of the procedure?
Correct Answer: D
Rationale: The correct answer is D because administering an analgesic medication 5 minutes before starting wound irrigation indicates an understanding of the procedure. Pain management is crucial to ensure client comfort during wound care.
Choice A is incorrect as a syringe with a catheter is not typically used for wound irrigation.
Choice B is incorrect as refrigerating the solution is unnecessary and may cause discomfort to the client.
Choice C is incorrect as using one pair of gloves for both dressing removal and irrigation increases the risk of cross-contamination.
Question 4 of 5
A nurse is assessing a client who is receiving a blood transfusion. The nurse notes lung crackles, hypoxia, and distended neck veins. Which of the following actions should the nurse take? (Select all that apply.)
Correct Answer: A,B,D,E
Rationale: The correct actions for the nurse to take in this scenario are A, B, D, and E. A diuretic can help manage fluid overload, oxygen can help alleviate hypoxia, stopping the transfusion is crucial to prevent further complications, and placing the client in high-Fowler's position can improve oxygenation. Administering epinephrine is not indicated as it is not a standard treatment for these symptoms. Obtaining a prescription for a diuretic is more urgent than administering one as the client is already showing signs of fluid overload. Administering epinephrine without assessing the client's condition further could worsen their symptoms.
Question 5 of 5
A nurse is assessing a client who has left-sided weakness following a stroke. Which of the following findings is the nurse's priority?
Correct Answer: C
Rationale: The correct answer is C: The client coughs frequently while eating. This is the priority finding because it indicates a risk for aspiration, a potentially life-threatening complication post-stroke. Aspiration occurs when food or liquids enter the airway instead of the esophagus, leading to choking or pneumonia. The nurse should address this immediately by modifying the client's diet consistency or positioning during meals to prevent aspiration.
The other choices are not the priority because:
A: The client's blood pressure being 142/94 mm Hg is elevated but not immediately life-threatening in this context.
B: Consuming only 25% of meals may indicate dysphagia or decreased appetite, which are important but not as urgent as the risk of aspiration.
D: Leaning to the left side while sitting is likely due to the left-sided weakness and can be addressed with positioning adjustments but is not as urgent as preventing aspiration.