ATI RN
ATI RN Fundamentals 2023 I Questions
Extract:
Question 1 of 5
A nurse is assessing a client who has risk factors for developing heart disease. Which of the following factors does the nurse recognize as a modifiable risk factor?
Correct Answer: D
Rationale: The correct answer is D: Physical inactivity. This is a modifiable risk factor because individuals can make lifestyle changes to increase physical activity levels, which can help reduce the risk of developing heart disease. Regular exercise can improve cardiovascular health, lower blood pressure, and reduce the risk of obesity.
A: Hypertension in a parent is not modifiable as it is a genetic predisposition.
B: Cultural beliefs do not directly impact heart disease risk and are not modifiable.
C: Air quality is an environmental factor that is not easily modifiable on an individual level.
In summary, physical inactivity is the only modifiable risk factor in the given choices, making it the correct answer.
Question 2 of 5
A nurse is caring for a client who has dysphagia. When assisting the client during breakfast, which of the following actions by the client indicates the nurse should intervene?
Correct Answer: B
Rationale: The correct answer is B. When a client has dysphagia, drinking thickened liquids with a straw can increase the risk of aspiration because the liquid may move too quickly through the straw. This can lead to choking or aspiration pneumonia.
Choices A, C, and D are all appropriate actions for a client with dysphagia. Adjusting the bed to 90° helps with swallowing, tucking the chin can prevent aspiration, and taking breaks while eating can reduce the risk of choking.
Question 3 of 5
A nurse is teaching a client how to self-administer heparin. Which of the following instructions should the nurse include in the teaching?
Correct Answer: B
Rationale: The correct answer is B: Inject 5.1 cm (2 in) away from the umbilicus. This instruction is crucial to prevent any potential bruising or irritation at the injection site. Injecting too close to the umbilicus can lead to discomfort and complications. Option A is incorrect as a smaller gauge needle is recommended for heparin injections to minimize tissue trauma. Option C is incorrect as air bubbles should be removed to prevent air embolism, not specifically related to heparin administration. Option D is incorrect as massaging the injection site can cause bruising and should be avoided.
Question 4 of 5
A nurse is caring for a client who is postoperative and is on bed rest. Which of the following actions should the nurse take to decrease the client’s risk of developing a pressure injury?
Correct Answer: C
Rationale: The correct answer is C: Ensure the client’s heels are not touching the mattress. This is important because pressure injuries commonly occur on bony prominences, such as the heels, due to prolonged pressure and friction. By ensuring the client’s heels are elevated off the mattress, the nurse can reduce the risk of pressure injury development in this area. Repositioning the client every 4 hours (choice
A) is important but may not specifically address the risk of pressure injury on the heels. Raising the head of the client’s bed to a 60° angle (choice
B) is more related to preventing aspiration in a postoperative client than preventing pressure injuries. Massaging the client’s bony prominences (choice
D) can actually increase the risk of skin breakdown due to friction and shearing forces.
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: C
Rationale: The correct answer is C: Recheck the client's BP in her other arm for comparison. This is the best course of action to ensure accuracy of the BP reading. By rechecking the BP in the other arm, the nurse can determine if the initial reading was accurate or if there are any significant differences between the arms. This can help identify any potential issues such as arterial blockages or other underlying conditions affecting the BP.
Choice A is incorrect because the width of the BP cuff should be 40% of the upper arm circumference, not 50%.
Choice B is not necessary unless the client is showing signs of distress or discomfort, as it is important to keep the client in the same position for consistent readings.
Choice D is unnecessary unless there are specific reasons to suspect inaccurate readings or if the client's condition changes significantly.
In summary, rechecking the BP in the other arm is the most appropriate action to verify the accuracy of the initial reading and ensure the client's safety.