ATI RN
ATI RN Fundamentals 2023 Questions
Extract:
Question 1 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: A
Rationale: The correct answer is A: A sharp decrease in blood pressure. An anaphylactic reaction is a severe allergic reaction that can occur rapidly after exposure to an allergen, such as medication. It can lead to a sudden drop in blood pressure due to widespread vasodilation and increased permeability of blood vessels. This can result in shock, a life-threatening condition.
Therefore, the nurse should identify a sharp decrease in blood pressure as a key indicator of an anaphylactic reaction.
Choices B, C, and D are incorrect as they are not typical signs of an anaphylactic reaction. Swelling in the feet, pain at the injection site, and a sudden decrease in heart rate are not specific to anaphylaxis.
Question 2 of 5
A nurse is planning care for a client who has a prescription for extremity restraints to both wrists. Which of the following actions should the nurse include in the plan of care?
Correct Answer: A,C,D
Rationale: The correct actions are A, C, and D.
A: Assessing skin temperature and color before applying restraints helps prevent skin breakdown.
C: Ensuring the bed is in the lowest position reduces fall risk and injury.
D: Padding bony prominences prevents pressure injuries.
B: Attaching restraints to the bed rail can cause harm if the client moves.
E: Allowing three fingers under restraints is too loose and can lead to escape or injury.
Question 3 of 5
A nurse is providing discharge teaching about safety considerations to an older adult client who lives at home. The client has heart failure and a new prescription for hydrochlorothiazide. Which of the following statements by the client indicates an understanding of the teaching?
Correct Answer: C
Rationale: The correct answer is C: "I will leave a light on in my bathroom at night." This statement indicates an understanding of the teaching because older adults with heart failure are at risk for falls due to potential nocturia (frequent need to urinate at night) caused by the diuretic effect of hydrochlorothiazide. Leaving a light on in the bathroom at night can help prevent falls.
Choice A is incorrect because weighing once weekly does not address the immediate safety concern related to falls.
Choice B is unrelated to safety considerations.
Choice D is incorrect as taking a hot bath before bed can potentially increase the risk of falls due to dizziness.
Question 4 of 5
A nurse is prioritizing care for a client. Which of the following procedures should the nurse perform first?
Correct Answer: D
Rationale: The correct answer is D: Endotracheal suctioning. This procedure should be prioritized as it helps maintain a patent airway, which is crucial for the client's oxygenation and ventilation. Without a clear airway, the client may experience respiratory distress or compromise. Urinary catheter care (
A) is important but not immediately life-threatening. Enteral feeding (
B) and wound irrigation (
C) can be delayed as they do not directly impact the client's airway. Endotracheal suctioning takes precedence over these procedures.
Question 5 of 5
A nurse is caring for a client who requires airborne precautions. The nurse is preparing to leave the client's room following a dressing change. Which of the following pieces of personal protective equipment should the nurse remove first?
Correct Answer: C
Rationale: The correct answer is C: Gloves. The nurse should remove gloves first after a dressing change to prevent contamination of other surfaces. Gloves are the primary barrier protecting the nurse from direct contact with bodily fluids. Removing gloves first helps minimize the risk of spreading pathogens. Removing eyewear, mask, or gown first could potentially expose the nurse to airborne pathogens or splash contamination. Removing the mask or gown first could also lead to contamination of the nurse's face or clothing. Removing gloves first ensures proper infection control practices are followed.