ATI RN
ATI RN Fundamentals 2023 Exam 5 Questions
Extract:
Question 1 of 5
A nurse is ambulating a client who is unsteady. The client begins to fall. Which of the following actions should the nurse take?
Correct Answer: C
Rationale: Moving quickly to a position in front of the client is not recommended. This action could result in both the nurse and the client falling, potentially causing injury to both parties. Remaining upright as the client falls toward them is incorrect. This action does not provide adequate support or control, increasing the risk of injury to the client. Allowing the client to slide down their outstretched leg is the correct action. This technique helps control the fall and minimizes the risk of injury by providing a controlled descent to the floor. Placing their arms around the client to prevent the fall is not advisable. This action can lead to both the nurse and the client falling, which could result in injuries.
Question 2 of 5
A nurse is administering multiple types of ophthalmic drops to a client. Which of the following actions should the nurse take?
Correct Answer: A
Rationale: Waiting 5 minutes between the administration of each medication is the most appropriate action. This allows each medication to be absorbed properly without being washed away by the subsequent drops. Adequate absorption ensures that each medication can exert its therapeutic effect effectively. Asking the client to close their eyes tightly after instilling each medication is not recommended. This action can force the medication out of the eye, reducing its effectiveness. Instead, clients should be advised to close their eyes gently to allow the medication to spread evenly across the eye surface. Holding the dropper 3 cm (1.2 in) away from the client's eye is too far. The recommended distance is about 1 to 2 cm (0.4 to 0.8 in) to ensure that the drops are accurately placed in the conjunctival sac without touching the eye or eyelashes, which could cause contamination. Massaging the client's eyelids for 20 seconds after instillation is not a standard practice for administering ophthalmic drops. This action could potentially irritate the eye or cause discomfort. Instead, gentle pressure can be applied to the inner corner of the eye (nasolacrimal duct) for a few seconds to prevent the medication from draining into the tear duct.
Question 3 of 5
A charge nurse is observing a staff nurse performing wound irrigation for a client who has a pressure injury. Which of the following actions by the staff nurse indicates an understanding of the procedure?
Correct Answer: B
Rationale: Refrigerating the solution before irrigation is not recommended. The solution should be at room temperature to avoid causing discomfort or vasoconstriction, which can impede the healing process. Administering an analgesic medication 5 minutes before starting irrigation is correct. This action helps manage the client's pain during the procedure, ensuring comfort and compliance. Using one pair of gloves for both dressing removal and irrigation is incorrect. The nurse should use separate pairs of gloves to prevent cross-contamination and maintain aseptic technique. Using a syringe with a catheter for wound irrigation is correct practice. This method allows for controlled and directed irrigation, ensuring the wound is properly cleaned.
Question 4 of 5
A nurse is assessing a client whose partner is receiving hospice care and is dying. The client states, 'I should start planning the trip that we want to take.' Which of the following ego-defense mechanisms is the client expressing?
Correct Answer: B
Rationale: Dissociation is a defense mechanism where a person disconnects from their thoughts, feelings, or sense of identity. It often occurs in response to trauma or extreme stress, allowing the individual to distance themselves from the reality of the situation. In this case, the client is not showing signs of dissociation, such as feeling detached from reality or experiencing memory gaps. Instead, they are avoiding the reality of their partner's condition. Denial is a defense mechanism where a person refuses to accept the reality of a situation to avoid dealing with painful emotions. The client's statement about planning a trip despite their partner's terminal condition indicates that they are not acknowledging the severity of the situation. This refusal to accept reality helps them cope with the emotional distress associated with their partner's impending death. Regression involves reverting to behaviors from an earlier stage of development when faced with stress. This might include actions like thumb-sucking, bed-wetting, or other childlike behaviors. The client's statement does not indicate a return to earlier developmental behaviors but rather a refusal to accept the current reality. Displacement is a defense mechanism where negative emotions are redirected from their original source to a less threatening target. For example, someone might take out their frustration with their boss on a family member. In this scenario, the client is not redirecting their emotions but rather avoiding the reality of their partner's condition.
Question 5 of 5
A nurse enters a client's room and finds the client on the floor having a seizure. Which of the following actions should the nurse take?
Correct Answer: C
Rationale: Lifting the client to the bed with assistance is not recommended during a seizure. Moving the client can increase the risk of injury to both the client and the nurse. The primary focus should be on ensuring the client's safety by preventing injury from nearby objects and allowing the seizure to run its course. Turning the client onto their back is not advisable during a seizure. This position can increase the risk of airway obstruction and aspiration. Instead, the client should be turned onto their side to maintain an open airway and allow any secretions to drain from the mouth, reducing the risk of aspiration. Clearing the nearby area of furniture is the most appropriate action. This helps to prevent the client from injuring themselves on hard or sharp objects during the seizure. Ensuring a safe environment is a key priority in managing a seizure, as it minimizes the risk of physical harm. Placing a tongue depressor in the client's mouth is an outdated and dangerous practice. It can cause injury to the client's teeth, mouth, or airway. There is also a risk of the client biting down and breaking the depressor, leading to choking hazards. Modern seizure management guidelines strongly advise against placing any objects in the client's mouth during a seizure.