ATI RN
ATI RN Fundamentals 2023 Questions
Extract:
Question 1 of 5
A nurse in a mental health clinic is caring for an older adult client who has depression and has stopped taking their medication. The client tells the nurse, 'I want to die now that my partner is gone.' Which of the following responses should the nurse make?
Correct Answer: B
Rationale:
Correct
Answer: B
Rationale: Asking the client directly if they have thought about harming themselves is crucial in assessing suicidal ideation. This response shows the nurse's concern for the client's safety and opens up a dialogue for further assessment and intervention.
Summary:
A: While discussing feelings with the provider is important, addressing immediate safety concerns takes precedence.
C: Inquiring about medication cessation is relevant but not as urgent as assessing suicidal thoughts.
D: Understanding the client's relationship is valuable, but safety assessment is the priority in this situation.
Question 2 of 5
A nurse is preparing to administer medications to a client. At which of the following times should the nurse compare the medication administration record and the medication label?
Correct Answer: B,C,E
Rationale: The correct times for the nurse to compare the medication administration record and the medication label are when removing the medication from the drawer, directly before administering the medication, and when preparing the medication dosage. Comparing the medication administration record with the label when removing the medication ensures that the correct medication is being taken out. Checking again directly before administration ensures the right medication is given to the right patient. Lastly, verifying the medication dosage during preparation ensures accurate dosing. The other options are incorrect because comparing at the end of the shift may lead to errors going unnoticed, reconciling counts of controlled substances is unrelated to checking medication accuracy, and comparing when reconciling counts may not catch errors in administration.
Question 3 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 4 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 5 of 5
A nurse is teaching a client how to self-administer heparin. Which of the following instructions should the nurse include in the teaching?
Correct Answer: C
Rationale: The correct answer is C: Inject 5.1 cm (2 in) away from the umbilicus. This instruction is important to prevent any damage to the abdominal organs near the umbilicus. Injecting heparin too close to the umbilicus can lead to injury or bleeding.
Choice A is incorrect because an 18-gauge, 1-inch needle is too large for subcutaneous injections like heparin administration.
Choice B is incorrect as massaging the injection site after withdrawing the needle can increase the risk of bruising or bleeding.
Choice D is incorrect as expelling air bubbles before injecting medication is essential for intravenous injections, not subcutaneous injections like heparin.