ATI RN
ATI RN Fundamentals 2023 Questions
Extract:
Question 1 of 5
A nurse is admitting a client who is at risk for falls to a medical-surgical unit. Which of the following actions should the nurse take?
Correct Answer: C
Rationale: The correct answer is C: Provide the client with a night light. This is important for fall prevention as it helps the client see the surroundings clearly during nighttime, reducing the risk of tripping or falling. Placing a night light in the client's room promotes safety and enhances visibility, especially during sleep or when getting up at night. Elevating full-length side rails (Option
A) may restrict the client's mobility and independence, increasing the risk of falls. Placing the bedside table away from the bed (Option
B) does not directly address fall prevention. Keeping the room temperature at 18°C (Option
D) is not directly related to fall prevention.
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: C
Rationale: The correct answer is C: "I will contact your provider to discuss your options." This response demonstrates the nurse's commitment to advocating for the client's wishes while ensuring appropriate communication with the healthcare provider to explore available treatment options. It respects the client's autonomy and decision-making process.
Incorrect
Choices:
A: Hospice care may not align with the client's current wishes for aggressive treatment.
B: While important, this response does not address the client's desire for treatment options.
D: This response may not be in line with the client's current mindset and can be seen as dismissive.
Overall, choice C is the most appropriate as it acknowledges the client's wishes and facilitates informed decision-making.
Question 3 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: A
Rationale: The correct answer is A: The client coughs frequently while eating. This is the priority finding as it indicates a risk of aspiration, which can lead to serious complications like pneumonia. The nurse should address this immediately to ensure the client's safety.
Choice B is not as urgent as the client's blood pressure is slightly elevated but not critically high.
Choice C, the client consuming 25% of meals, is concerning but not as immediately life-threatening as aspiration.
Choice D, the client leaning to the left side while sitting, may be related to the left-sided weakness but does not pose an immediate risk to the client's health.
Question 4 of 5
A nurse is planning care for a client who is immobile. Which of the following actions should the nurse include in the plan of care?
Correct Answer: B
Rationale: The correct answer is B: Use trochanter rolls beside the client's legs. Trochanter rolls help maintain proper alignment of the hips and prevent external rotation of the legs, reducing the risk of pressure ulcers and hip dislocation. Logrolling (choice
A) is not necessary unless specifically indicated for spinal precautions. Placing the client's arms at their side (choice
C) may restrict circulation and lead to discomfort. Crossing the client's ankles (choice
D) could cause pressure ulcers and impair circulation.
Question 5 of 5
A nurse is collecting a blood pressure (BP) reading from a client who is sitting in a chair. The nurse determines that the client's BP is 158/96 mm Hg. Which of the following actions should the nurse take?
Correct Answer: B
Rationale: The correct answer is B: Recheck the client's BP in her other arm for comparison. This is the best course of action to confirm the accuracy of the initial BP reading. Taking the BP in both arms helps identify any discrepancies due to differences in blood pressure between arms or measurement errors. It also allows for better assessment of the client's overall blood pressure status.
Choice A is incorrect because the width of the BP cuff should be about 40% of the upper arm circumference, not 50%.
Choice C is inappropriate as waiting 30 minutes without immediate action can be risky if the high BP is indicative of a serious condition.
Choice D is unnecessary and may not provide additional information about the client's BP accuracy.