ATI RN
ATI Nur 231 Fundamentals Exam Questions
Extract:
Question 1 of 5
A nurse is assessing a client who is experiencing complications due to immobility. Which of the following findings should the nurse expect? (Select all that apply)
Correct Answer: B,D,E
Rationale: Contractures of the extremities: Contractures are a common complication of immobility. When a joint is not moved regularly, the muscles and tissues can shorten, leading to stiffness and loss of mobility in the affected area. Pressure ulcers: Pressure ulcers, also known as bedsores, are a significant risk for individuals with limited mobility. They develop due to prolonged pressure on the skin, particularly over bony prominences, leading to skin breakdown and tissue damage. Crackles in the lungs: Crackles can be heard during auscultation in patients who are immobile. They may develop due to fluid accumulation in the lungs, atelectasis, or pneumonia, which are all more likely to occur in individuals with limited mobility.
Question 2 of 5
A nurse is assisting with transferring a client from the bed to a wheelchair. Which of the following actions should the nurse take?
Correct Answer: B
Rationale: Lock the wheels of the bed and the wheelchair: This is a crucial safety measure. Locking the wheels prevents both the bed and the wheelchair from moving during the transfer, reducing the risk of falls or injuries for both the client and the nurse. Ensuring stability is essential for a safe and effective transfer.
Question 3 of 5
A nurse is providing oral care for a client who had has impaired upper extremity strength. Which of the following actions should the nurse take?
Correct Answer: A
Rationale: Provide the client with an electric toothbrush: An electric toothbrush is an appropriate option for a client with impaired upper extremity strength. It requires less physical effort to use compared to a manual toothbrush.
Question 4 of 5
Which activity should the nurse implement to decrease shearing force on a client's stage II pressure injury?
Correct Answer: A
Rationale: Preventing the client from sliding in bed: This activity directly addresses shearing forces, which occur when the skin is pulled in one direction while the underlying tissues move in another.
Question 5 of 5
The nurse prepares to meet with assigned clients after receiving hand-off communication. Which statement or question demonstrates that the nurse is in the termination phase with a client?
Correct Answer: D
Rationale: I’m going to miss talking with you every day but you are better and ready to go home now: This statement clearly indicates the termination phase of the nurse-client relationship. It acknowledges the emotional aspect of the relationship while confirming that the client is prepared for discharge, signifying the conclusion of the care provided.