ATI RN
ATI RN Fundamentals Updated 2023 Exam Questions
Extract:
Question 1 of 5
A nurse in an emergency department is assessing a client who reports right lower quadrant pain, nausea, and vomiting for the past 48 hr. Which of the following actions should the nurse take first?
Correct Answer: D
Rationale: The correct answer is D: Auscultate bowel sounds. This is the first action the nurse should take as it can provide crucial information about the client's condition, particularly in suspected appendicitis. Absence of bowel sounds in the right lower quadrant may indicate an inflamed appendix, requiring immediate medical attention. Administering an antiemetic (choice
A) or pain medication (choice
B) without assessing the bowel sounds first could mask important symptoms. Palpating the abdomen (choice
C) can potentially worsen the client's condition if appendicitis is present.
Therefore, auscultating bowel sounds is the priority to guide further assessment and intervention.
Question 2 of 5
A nurse is caring for a client following a bilateral mastectomy. The client is often tearful and avoids looking at her dressings. Which of the following actions should the nurse take first?
Correct Answer: A
Rationale: The correct answer is A: Identify the impact of the mastectomy on the client's body image. The nurse should first assess the client's emotional state and address her feelings of distress and avoidance. By identifying the impact of the mastectomy on body image, the nurse can provide emotional support and appropriate interventions. This step prioritizes the client's emotional well-being and helps establish trust. Encouraging the client to assist with dressing changes (
B) may not address the underlying emotional distress. Referring the client to a support group (
C) may be beneficial but should come after addressing the immediate emotional needs. Providing a mirror (
D) may worsen the client's distress if she is not ready to confront her incisions.
Question 3 of 5
A nurse is teaching a group of newly licensed nurses about the Braden scale. Which of the following responses by a newly licensed nurse indicates an understanding of the teaching?
Correct Answer: B
Rationale:
Correct Answer: B - The scale measures six elements.
Rationale: The Braden scale is used to assess a patient's risk for developing pressure ulcers and consists of six elements: sensory perception, moisture, activity, mobility, nutrition, and friction/shear. Understanding this indicates knowledge of the scale's components.
Incorrect
Choices:
A: Each element has a range from one to five points - This is incorrect because the elements are not scored on a range from one to five.
C: The client's age is part of the measurement - Age is not a factor in the Braden scale assessment.
D: The higher the score, the higher the pressure injury risk - This is incorrect as a higher score on the Braden scale indicates a lower risk of pressure ulcers.
Question 4 of 5
A nurse is documenting a dressing change for a client who has a pressure injury. Which of the following entries by the nurse demonstrates correct documentation?
Correct Answer: C
Rationale:
Correct Answer: C
Rationale:
1. "New dressing applied as prescribed" - This entry documents the action taken by the nurse, ensuring compliance with the care plan.
2. "No drainage on old dressing" - This indicates the status of the wound, showing that there is no abnormal discharge.
3. It provides specific and relevant information related to the dressing change, demonstrating thorough documentation.
Incorrect
Choices:
A: Irrelevant information about premedication with MSO, subq prior to dressing change.
B: Subjective assessment without concrete details or objective findings.
D: Lack of specific details or assessment of the wound's condition.
Overall, choice C provides clear, concise, and relevant information essential for accurate documentation.
Question 5 of 5
A nurse is caring for a client who has a high fever. Which of the following actions should the nurse take?
Correct Answer: C
Rationale: The correct action is C: Give the client a sponge bath using an alcohol-water solution. This helps to reduce the client's body temperature through evaporative cooling. Alcohol evaporates quickly, enhancing heat loss. Applying a bath blanket between the client and a cooling blanket (
A) may not be as effective in reducing the client's temperature as a sponge bath. Covering the client with heavy blankets after shivering subsides (
B) may trap heat and worsen the fever. Placing ice packs on the client's neck and behind the knees (
D) may cause vasoconstriction and hinder heat loss.