ATI RN
ATI RN Fundamentals 2023 II 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? (Select all that apply.)
Correct Answer: A,B,D,E
Rationale: The correct actions for the nurse to take in this scenario are A, B, D, and E. A diuretic can help manage fluid overload, oxygen can help alleviate hypoxia, stopping the transfusion is crucial to prevent further complications, and placing the client in high-Fowler's position can improve oxygenation. Administering epinephrine is not indicated as it is not a standard treatment for these symptoms. Obtaining a prescription for a diuretic is more urgent than administering one as the client is already showing signs of fluid overload. Administering epinephrine without assessing the client's condition further could worsen their symptoms.
Question 2 of 5
A nurse is teaching a client how to self-administer daily low-dose heparin injections. Which of the following factors is most likely to increase the client's motivation to learn?
Correct Answer: B
Rationale: The correct answer is B because when a client believes that their needs will be met through education, they are more likely to be motivated to learn. This belief creates a sense of purpose and relevance, driving the client to engage in the learning process.
Explanation of other options:
A: While it's important for the nurse to explain the need for education, this may not directly increase the client's motivation if they don't see the relevance to their needs.
C: Seeking family approval may provide external motivation but may not necessarily lead to intrinsic motivation for learning.
D: Nurse empathy is important for building rapport but may not be the primary factor in increasing motivation to learn.
Question 3 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 4 of 5
A nurse in a mental health clinic is caring for an older adult client who has depression and has stopped taking their medication. The client tells the nurse, 'I want to die now that my partner is gone.' Which of the following responses should the nurse make?
Correct Answer: A
Rationale:
Correct Answer: A. "Have you thought about harming yourself?"
Rationale: This response is crucial in assessing the client's risk of suicide. It shows the nurse's immediate concern for the client's safety and opens a dialogue to understand the severity of the client's suicidal ideation. By directly addressing the client's statement about wanting to die, the nurse can determine the level of risk and take appropriate actions to ensure the client's safety.
Incorrect
Choices:
B: "Tell me more about your partner." - This response does not address the immediate concern of suicidal ideation and misses the opportunity to assess the client's safety.
C: "You should discuss these feelings with your provider." - While important, this response does not address the urgent need to assess the client's risk of harm to self.
D: "Why did you stop taking your medication?" - While medication adherence is important, the client's statement about wanting to die takes precedence in this situation.
Question 5 of 5
A nurse is caring for a client who has left lower-lobe atelectasis. In which of the following positions should the nurse place the client for postural drainage?
Correct Answer: C
Rationale: The correct answer is C: Side-lying with the right side of the chest elevated. This position allows gravity to help drain secretions from the left lower lobe, promoting lung expansion. Placing the client in a side-lying position with the right side elevated facilitates drainage and prevents pooling of secretions. Option A (Prone with pillows under the lower extremities) would not effectively target the left lower lobe. Option B (Supine in low-Fowler's position) may not provide adequate drainage for the specific lobe affected. Option D (Right lateral in Trendelenburg position) is incorrect as Trendelenburg position is not recommended for postural drainage due to increased risk of complications.