ATI RN
ATI RN Fundamentals 2023 II Questions
Extract:
Question 1 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: C
Rationale: The correct answer is C: The client coughs frequently while eating. This is the priority finding because it indicates a risk for aspiration, a potentially life-threatening complication post-stroke. Aspiration occurs when food or liquids enter the airway instead of the esophagus, leading to choking or pneumonia. The nurse should address this immediately by modifying the client's diet consistency or positioning during meals to prevent aspiration.
The other choices are not the priority because:
A: The client's blood pressure being 142/94 mm Hg is elevated but not immediately life-threatening in this context.
B: Consuming only 25% of meals may indicate dysphagia or decreased appetite, which are important but not as urgent as the risk of aspiration.
D: Leaning to the left side while sitting is likely due to the left-sided weakness and can be addressed with positioning adjustments but is not as urgent as preventing aspiration.
Question 2 of 5
A nurse is assessing a client who received an IM antibiotic injection 15 min ago. Which of the following findings should the nurse identify as an indication of a possible anaphylactic reaction to the medication?
Correct Answer: B
Rationale: The correct answer is B: A sharp decrease in blood pressure. An anaphylactic reaction is a severe allergic reaction that can lead to a sudden drop in blood pressure, known as anaphylactic shock. This is a life-threatening emergency that requires immediate intervention. A sudden decrease in heart rate (
A) is not typically associated with an anaphylactic reaction. A feeling of swelling in the feet (
C) could indicate a localized reaction but is not specific to anaphylaxis. Pain at the injection site (
D) is a common side effect of IM injections but not a sign of anaphylactic reaction.
Question 3 of 5
A nurse is teaching a client who has decreased mobility about passive range-of-motion exercises. Which of the following statements should the nurse make?
Correct Answer: D
Rationale: The correct answer is D: "I will repeat these movements 3 to 5 times." This is the best choice because passive range-of-motion exercises should be repeated multiple times to prevent joint stiffness and contractures. Moving joints quickly (
A) may cause injury. Performing the exercises only once per day (
B) may not be sufficient for maintaining joint mobility. Moving joints to the point of mild pain (
C) can lead to discomfort and potential harm.
Therefore, option D is the most appropriate for promoting joint mobility and preventing complications.
Question 4 of 5
A nurse is teaching a client about progressing from a clear liquid diet to a full liquid diet. Which of the following food selections by the client indicates an understanding of the teaching?
Correct Answer: D
Rationale: The correct answer is D: Pudding. Pudding is part of a full liquid diet, which includes foods that are liquid at room temperature and don't require chewing. This demonstrates understanding of the progression from a clear liquid diet to a full liquid diet. Bananas (
A) and cooked vegetables (
B) require chewing and are not part of a full liquid diet. Yogurt with fruit (
C) contains solid pieces of fruit, which may not be suitable for a full liquid diet. In summary, pudding is the appropriate choice as it aligns with the requirements of a full liquid diet, while the other options do not meet this criteria.
Question 5 of 5
A nurse is preparing to teach a female client about osteoporosis prevention. Which of the following recommendations should the nurse make for this client?
Correct Answer: B
Rationale: The correct answer is B: Walk for 30 minutes three to five times each week. Weight-bearing exercises, like walking, help improve bone density and prevent osteoporosis. Walking also helps strengthen muscles and improve balance, reducing the risk of falls and fractures. Performing water aerobics (choice
A) can be beneficial for overall health but may not have the same impact on bone density as weight-bearing exercises. Increasing intake of vitamin B12 (choice
C) is important for overall health but not specifically for osteoporosis prevention. Maintaining a lean body mass (choice
D) is beneficial, but the focus should be on weight-bearing exercises for osteoporosis prevention.