ATI RN
ATI RN Fundamentals Updated 2023 Exam Questions
Extract:
Question 1 of 5
A nurse is assessing a client who has diabetes mellitus prior to performing a blood glucose test. Which of the following findings should indicate to the nurse that the client has hyperglycemia?
Correct Answer: B
Rationale: The correct answer is B: Thirst. Hyperglycemia leads to increased glucose levels in the blood, causing the body to try to dilute the sugar by increasing urination, leading to dehydration and thirst. Confusion (
A) can indicate hypoglycemia, not hyperglycemia. Cold skin (
C) and shakiness (
D) are not specific signs of hyperglycemia.
Question 2 of 5
A charge nurse in a long-term care facility is preparing an educational program about delirium for newly hired nurses. Which of the following statements should the nurse plan to include?
Correct Answer: D
Rationale: The correct answer is D: Delirium has an abrupt onset. Delirium is characterized by a sudden and fluctuating change in mental status. This rapid onset is a key feature that distinguishes delirium from other cognitive disorders. Delirium can develop over hours to days and is often reversible when the underlying cause is identified and treated promptly.
A: Incorrect. Delirium can disrupt a client's sleep cycle, leading to disturbances like insomnia or excessive drowsiness.
B: Incorrect. Delirium can impact a client's perception of their environment, causing confusion, disorientation, and hallucinations.
C: Incorrect. Delirium typically has a rapid onset rather than a slow progression. It is important to recognize and address delirium promptly to prevent complications.
Question 3 of 5
A nurse working on a medical-surgical unit is making client assignments for an upcoming shift. Which of the following tasks should the nurse assign to an assistive personnel?
Correct Answer: D
Rationale: The correct answer is D. Assigning the task of assisting with ambulation for a client who has a pulmonary infection to an assistive personnel is appropriate because it is a routine activity that does not require specialized nursing knowledge or skills. Ambulation is a basic care task that can be safely performed by assistive personnel under the supervision of a nurse. It helps promote mobility and prevent complications in clients with pulmonary infections.
Choices A, B, and C involve more complex and skilled nursing interventions that require assessment, critical thinking, and nursing judgment. Inserting a suppository, teaching how to use an incentive spirometer, and irrigating a wound all require specialized nursing knowledge and skills.
Therefore, they should not be assigned to assistive personnel.
In summary, assigning tasks that are routine and do not require nursing judgment to assistive personnel helps optimize nursing resources and promote safe and efficient care delivery.
Question 4 of 5
A nurse is performing postural drainage with percussion and vibration for a client who has cystic fibrosis. Which of the following actions should the nurse take?
Correct Answer: B
Rationale: The correct answer is B: Cover the area of percussion with a towel. This is important to prevent skin irritation or discomfort during the procedure. The towel acts as a barrier between the client's skin and the nurse's hand, reducing friction and protecting the skin. Performing percussion directly on the skin can cause redness, bruising, or discomfort, so covering the area with a towel is a standard practice to ensure the client's safety and comfort.
Choice A is incorrect because percussion should be performed over specific areas of the chest, not the lower back.
Choice C is incorrect as postural drainage should be scheduled before meals to prevent aspiration.
Choice D is incorrect as clients should exhale slowly and relax during vibration to promote airway clearance.
Question 5 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: The correct answer is B because the Braden scale measures six elements: sensory perception, moisture, activity, mobility, nutrition, and friction/shear. Each element is rated on a scale from 1 to 4, except for friction/shear, which is rated from 1 to 3. Understanding this key aspect of the Braden scale demonstrates a comprehensive knowledge of the tool.
Choice A is incorrect because each element is rated on a scale from 1 to 4 or 1 to 3, not 1 to 5.
Choice C is incorrect because the client's age is not a factor in the Braden scale measurement.
Choice D is incorrect because the higher the score on the Braden scale, the lower the pressure injury risk, not higher.