ATI RN
ATI RN Fundamentals 2023 Questions
Extract:
Question 1 of 5
A nurse is assessing a client who is receiving a blood transfusion. The nurse notes lung crackles, hypoxia, and distended neck veins. Which of the following actions should the nurse take?
Correct Answer: A,B,C
Rationale:
Correct Answer: A, B, C
Rationale:
A: Placing the client in high-Fowler's position helps improve lung expansion and oxygenation.
B: Administering oxygen is crucial to treat hypoxia and improve oxygen levels in the blood.
C: Stopping the transfusion is necessary as the client is showing signs of fluid overload, which can lead to heart failure.
Incorrect choices:
D: Administering a diuretic may worsen the situation by further decreasing fluid volume.
E: Administering epinephrine is not indicated for these symptoms and can worsen the client's condition.
Question 2 of 5
A nurse is performing an eye assessment for a newly admitted client. Which of the following findings should the nurse expect?
Correct Answer: A
Rationale: The correct answer is A: Eyelashes that curl slightly outward. This finding is expected during an eye assessment as it indicates normal eyelash orientation. The eyelashes help protect the eyes from foreign objects.
Choices B, C, and D are incorrect. B is incorrect as the normal blink rate is 15 to 20 times per minute, not 30 to 35. C is incorrect because normal pupil size is 2 to 4 mm in diameter, not 8 to 9 mm. D is incorrect as corneas should be clear, not opaque.
Question 3 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: B
Rationale: The correct answer is B: Recheck the client's BP in her other arm for comparison. This is the best course of action to confirm the accuracy of the initial BP reading. Taking the BP in both arms helps identify any discrepancies due to differences in blood pressure between arms or measurement errors. It also allows for better assessment of the client's overall blood pressure status.
Choice A is incorrect because the width of the BP cuff should be about 40% of the upper arm circumference, not 50%.
Choice C is inappropriate as waiting 30 minutes without immediate action can be risky if the high BP is indicative of a serious condition.
Choice D is unnecessary and may not provide additional information about the client's BP accuracy.
Extract:
Diagnostic Results
1000:
• Prealbumin level 13 mg/dL (15 to 36 mg/dL)
• Cholesterol 210 mg/dL (less than 200 mg/dL)
• Fasting glucose 110 mg/dL (70 to 110 mg/dL)
Medical History
0800:
The client has a history of malnutrition, hyperlipidemia, and diabetes mellitus. Mini Nutritional Assessment screening tool score of 7 points (0 to 14 points)
Question 4 of 5
A nurse is caring for a client who is scheduled for surgery. Exhibits The nurse is reviewing the client's medical record. Which of the following findings places the client at risk for delayed wound healing? Select all that apply.
Correct Answer: C,D,F
Rationale:
Correct Answer: C, D, F
Rationale:
C: History of malnutrition - Malnutrition leads to a deficiency in essential nutrients needed for wound healing, impairing the body's ability to repair tissues.
D: History of diabetes mellitus - Diabetes can lead to impaired circulation and nerve damage, both of which can delay wound healing.
F: Prealbumin level - Prealbumin is a marker of protein status and low levels indicate poor nutritional status, which can impact wound healing.
Incorrect
Choices:
A: Mini Nutritional Assessment screening tool score - While this tool assesses nutritional status, it does not directly indicate a risk for delayed wound healing.
B: History of hyperlipidemia - Hyperlipidemia is elevated levels of lipids in the blood and is not directly related to delayed wound healing.
E: Cholesterol level - Cholesterol level alone does not necessarily correlate with delayed wound healing risk.
Extract:
Question 5 of 5
A nurse is caring for a client who had a stroke and coughs frequently when swallowing. The nurse should request a referral to which of the following members of the interdisciplinary team?
Correct Answer: A
Rationale: The correct answer is A: Speech-language pathologist. This professional specializes in evaluating and treating swallowing difficulties, known as dysphagia, which is common after a stroke. The speech-language pathologist can assess the client's swallowing function, provide strategies to improve safety during meals, and recommend appropriate diet modifications. The other choices, such as social worker, physical therapist, and occupational therapist, do not have the specific expertise in managing swallowing disorders like a speech-language pathologist does in this scenario.