ATI RN
RN ATI FUNDAMENTALS 2024 EXAM Questions
Extract:
Nurses' Notes
1100: Client reports fever, chills, cough, and night sweats for past 2 weeks. Client has recently traveled outside of the country. Lethargic, but oriented to person, place, and time. Crackles heard in lower lobes of lungs upon auscultation. Cough is productive with small amounts of blood. Reports tightness in chest and pain when coughing. Reports losing 5 Ib in the last week. Has no appetite and is nauseated. Obtained blood work, chest x-ray, and sputum as prescribed.
Question 1 of 5
A nurse is admitting a client to a healthcare facility. The nurse is placing the client on isolation precautions. Which of the following interventions should the nurse include? Select all that apply.
Correct Answer: A, B, C, E
Rationale:
Correct Answer: A, B, C, E
Rationale:
A: Wearing an N95 mask helps prevent the spread of airborne infections.
B: Placing a container for soiled linens inside the room prevents contamination of other areas.
C: Placing the client in a negative airflow room helps contain airborne pathogens.
E: Wearing a sterile water-resistant gown within 3 feet of the client prevents contact transmission.
Incorrect
Choices:
D: Removing the mask after exiting the room increases the risk of spreading infection.
F & G: No additional choices provided, so not applicable.
Extract:
Question 2 of 5
A nurse is preparing to administer enoxaparin subcutaneously to a client. Which of the following actions should the nurse take?
Correct Answer: A
Rationale: The correct answer is A: Administer the medication with the needle at a 45° angle. This is the correct action because enoxaparin is a subcutaneous medication that should be injected at a 45° angle to ensure proper absorption and reduce the risk of tissue damage. Administering it at this angle helps to ensure that the medication is effectively delivered into the subcutaneous tissue.
Choice B is incorrect as the administration site is not dependent on the client's dominant arm.
Choice C is incorrect as pulling the skin layer downward is not necessary for subcutaneous injections.
Choice D is incorrect as massaging the injection site after administration can lead to bruising and should be avoided.
Question 3 of 5
A nurse is using an open irrigation technique to irrigate a client's indwelling urinary catheter. Which of the following actions should the nurse take?
Correct Answer: C
Rationale: The correct answer is C: Subtract the amount of irrigant used from the client's urine output. This is important because when using an open irrigation technique, the nurse needs to account for the amount of irrigant introduced into the catheter to ensure accurate monitoring of urine output. By subtracting the amount of irrigant used from the total urine output, the nurse can accurately assess the client's true urine output.
Choice A is incorrect because placing the client in a semi-lying position is not directly related to the irrigation technique.
Choice B is incorrect as instilling a specific amount of 15 mL of irrigation fluid with each flush is not a standard practice for open irrigation technique.
Choice D is incorrect as the size of the syringe used for irrigation is not specified in standard guidelines.
Extract:
Nurses' Notes O Measure the clents intake and output,
1000; O Transfer the client from wheelchar o bed. Client states, *| am unable to eat anything without vomiting." Client reports pain in left upper quadrant of abdomen that radiates to their back. States that painisa"7" 0na 01010 pain L] Colect datasbout the clents pain evel. scale. Bruising noted on client's abdomen. Client is pale and diaphoretic. Provider prescribed blood work, abdominal CT, and NG tube insertion with low-intermittent decompression. IV fuids started and infusing in lefc peripheral IV site
Question 4 of 5
A nurse is caring for a client who has pancreatitis. Select the 3 tasks the nurse should delegate to an assistive personnel (AP). First Clinic Visit: Client arrives to clinic with report of increasing shortness of breath, fatigue, and weakness. States they get short of breath with minimal activity. Client is alert and oriented to person, place, and time. Moves all extremities well, follows simple commands. Sinus tachycardia, Pulses to lower extremities weak with +2 dependent edema present, Slightly labored respirations at rest. Chest with wheezes and crackles in the bases. Reports productive cough, especially during the overnight hours. Bowel sounds all present. Abdomen distended. Reports bowel movement this am. States voiding without difficulty, clear yellow urine. Teaching provided on nutrition therapy and adhering to a low-sodium diet, monitoring fluid intake, and lifestyle changes for heart failure. Provided medication teaching following provider's increase in furosemide dosage from.
Correct Answer: A, B, C
Rationale:
Correct Answer: A, B, C
Rationale:
A: Documenting vital signs is within the scope of practice for an assistive personnel (AP) and helps monitor the client's condition.
B: Measuring intake and output is a task that can be delegated to an AP and is essential for assessing fluid balance.
C: Transferring the client from wheelchair to bed is a task that an AP can safely perform to assist with the client's mobility.
Incorrect
Choices:
D: Inserting an NG tube requires specialized training and is a nursing task that should not be delegated to an AP.
E:
F:
G:
Summary: The correct tasks delegated to an AP involve activities that are within their scope of practice and do not require specialized nursing skills. Tasks like measuring vital signs, intake and output, and assisting with transfers are appropriate for delegation to an AP, while tasks like inserting an NG tube should be performed by a nurse.
Extract:
Nurses' Notes: Day 1
Lactated Ringer'sat 100 mbhr infusing into a 20-guage IV catheter in left hand. IV ressing dry and Intact. IV site without redness or swelling. IV fluld infusing vl [ Place a pressure chessing over the IV site.
(03 Apply heat to the clients left hand.
Day2 [ start.a newIV inthe clent’s eft hand. IV site edematous. Skin surrounding catheter site taut blanched, and cool to touch. IV fluid not nfusing.
Question 5 of 5
A nurse is caring for a client who has a peripheral IV inserted for fluid. The nurse is assessing the client. Which of the following actions should the replacement nurse take? Select all that apply. Nurses' Notes: Day 1: Client's left arm. Lactated Ringer's at 100 mL/hr infusing into a 20-gauge IV catheter in left hand. IV dressing dry and intact. IV site without redness or swelling. IV fluid infusing well. Day 2: Start a new IV in the client's left hand. IV site edematous. Skin surrounding catheter site taut, blanched, and cool to touch. IV fluid not infusing.
Correct Answer: A, B, C
Rationale:
Correct Answer: A, B, C
Rationale:
A: Stop the IV infusion - The client's IV site is showing signs of infiltration (edematous, cool skin, IV fluid not infusing), which can lead to tissue damage. Stopping the infusion is crucial to prevent further harm.
B: Place a pressure dressing over the IV site - A pressure dressing can help reduce swelling and prevent further infiltration of fluid into the surrounding tissues.
C: Apply heat to the client's left hand - Applying heat can help dilate blood vessels and improve circulation, which may help reduce the effects of infiltration and promote tissue healing.
Summary of Incorrect
Choices:
D: Starting a new IV in a different site is not necessary at this moment. The priority is to address the infiltration issue with the current IV.
E, F, G: No additional choices were provided, but they would likely be incorrect as they do not address the immediate concern of the IV site infiltration.