ATI RN
ATI RN Fundamentals 2023 II 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: A
Rationale:
Correct Answer: A. "Have you thought about harming yourself?"
Rationale: This response is crucial in assessing the client's risk of suicide. It shows the nurse's immediate concern for the client's safety and opens a dialogue to understand the severity of the client's suicidal ideation. By directly addressing the client's statement about wanting to die, the nurse can determine the level of risk and take appropriate actions to ensure the client's safety.
Incorrect
Choices:
B: "Tell me more about your partner." - This response does not address the immediate concern of suicidal ideation and misses the opportunity to assess the client's safety.
C: "You should discuss these feelings with your provider." - While important, this response does not address the urgent need to assess the client's risk of harm to self.
D: "Why did you stop taking your medication?" - While medication adherence is important, the client's statement about wanting to die takes precedence in this situation.
Question 2 of 5
A nurse is conducting the Weber's test on a client. Which of the following is an appropriate action for the nurse to take?
Correct Answer: C
Rationale: The correct answer is C: Place an activated tuning fork in the middle of the client's forehead. This is the appropriate action for the Weber's test because it helps assess for asymmetrical hearing loss. Placing the tuning fork on the forehead allows sound to be conducted through bone, bypassing the outer and middle ear. If the client hears the sound more in one ear than the other, it indicates conductive hearing loss in the ear that hears it less. Whispering words (
B) and delivering high-pitched sounds (
A) are not part of the Weber's test. Holding the tuning fork against the mastoid process (
D) is part of the Rinne test, not the Weber's test.
Extract:
Exibit 1
Provider Prescriptions
Day 4, 1500:
Discharge prescriptions:
Cephalexin 500 mg PO every 6 hr for 5 days Prednisone 40 mg PO daily for 5 days Home oxygen 3 L/min via nasal cannula
Exibit 2
Vital Signs
Day 1, 1100:
Temperature 39.1° C (102.4° F) Pulse rate 102/min Respiratory rate 26/min
Blood pressure 122/80 mm Hg Oxygen saturation 86% on room air Weight 90.7 kg (200 lb)
Day 2, 1200:
Temperature 38° C (100.4° F) Pulse rate 100/min Respiratory rate 22/min
Blood pressure 120/74 mm Hg
Oxygen saturation 88% on nasal cannula at 2 L/min Day 3, 1200:
Température 37.2° C (98.9" F) Pulse rate 90/min
Respiratory rate 20/min
Blood pressure 120/72 mm Hg
Exibit 3
Medication Administration Record
Day 1, 1500:
Cefazolin 500 mg every 12 hr IV Dexamethasone 15 mg every 6 hr IV Day 3, 1200:
Discontinue dexamethasone 15 mg every 6 hr IV Prednisone 40 mg PO daily
Day 4, 1500:
Discontinue cefazolin 500 mg every 12 hr IV
Question 3 of 5
A nurse is caring for a client who has pneumonia. Which of the following instructions should the nurse include in the teaching? (Select all that apply.)
Correct Answer: D,E,F
Rationale:
Correct Answer: D, E, F
Rationale:
D: Steroid medication should be taken in the morning - Steroid medication is typically taken in the morning to align with the body's natural cortisol production.
E: The steroid dose will decrease each day - Steroid therapy is usually tapered off gradually to prevent withdrawal symptoms.
F: Ensure the oxygen delivery system is at least 8 feet from any heat source - This is important to prevent the risk of fire or explosion.
Incorrect
Choices:
A: Store the oxygen cylinder wrench with the oxygen tank - This is incorrect as the wrench should be stored separately for easy access during emergencies.
B: Antibiotic therapy should be taken for 10 days - The duration of antibiotic therapy may vary depending on the specific antibiotic and the severity of the infection. It is not always 10 days.
C: Adjust the oxygen flow rate as needed to ease breathing - The oxygen flow rate should be set according to the healthcare provider's instructions and not adjusted arbitrarily.
G
Extract:
Question 4 of 5
A nurse is teaching a client who can only bear weight on one leg how to ambulate using crutches. Which of the following crutch gaits should the nurse plan to instruct the client to use?
Correct Answer: D
Rationale: The correct answer is D: Three-point gait. This gait is appropriate for a client who can only bear weight on one leg. In a three-point gait, the client moves both crutches and the affected leg forward together, then advances the unaffected leg. This gait provides maximum support and stability for the client while keeping weight off the affected leg. Other options are incorrect: A: Four-point gait involves alternating movement of crutches and feet, not suitable for one-legged weight-bearing. B: Two-point gait requires partial weight-bearing on both legs, not appropriate for this client. C: Swing-through gait involves swinging both legs through, unsuitable for one-legged weight-bearing.
Question 5 of 5
A nurse is prioritizing care for a client. Which of the following procedures should the nurse perform first?
Correct Answer: C
Rationale: The correct answer is C: Endotracheal suctioning. This procedure should be prioritized first as it helps maintain a clear airway, ensuring adequate oxygenation and ventilation for the client. Without proper air exchange, the client's health can deteriorate rapidly. Enteral feeding, urinary catheter care, and wound irrigation are important but can be done after ensuring the client's airway is clear. Endotracheal suctioning takes precedence over these procedures in emergency situations.