ATI RN
RN-ATI-Fundamentals-of-Nursing-2023-2024 Questions
Extract:
Question 1 of 5
A nurse is assessing an older adult client's risk for falls. Which of the following assessments should the nurse use to identify the client's safety needs? (Select all that apply.)
Correct Answer: B,C,D,E
Rationale: The correct assessments for identifying an older adult client's safety needs are B, C, D, and E. Pupil clarity is crucial for detecting any visual impairments that may increase fall risk. The appearance of bulbar conjunctivae can indicate underlying eye conditions affecting vision and balance. Assessing visual fields helps identify potential blind spots that may contribute to falls. Visual acuity is essential for clear vision and spatial awareness, both critical for preventing falls.
Choices A and F have no direct relevance to assessing fall risk in older adults, making them incorrect options.
Question 2 of 5
A nurse is caring for a child who has a prescription for a blood transfusion. The child's parents have refused the treatment due to their religious beliefs. Which of the following actions should the nurse take?
Correct Answer: A
Rationale: The correct answer is A: Examine personal values about the issue. The nurse should reflect on their own beliefs and values to ensure they can provide unbiased care. This step is essential to maintain professionalism and respect for the parents' autonomy. It allows the nurse to approach the situation with empathy and understanding.
B: Telling the parents that the procedure is necessary may come off as dismissive of their beliefs and could create conflict.
C: Informing the parents that staff does not require their consent is unethical and goes against the child's and parents' rights. It disregards their autonomy.
D: Contacting a spiritual support person may be helpful, but it should not be the first step. The nurse should first address their own values and then involve spiritual support if needed.
In summary, option A is the best course of action as it promotes respectful and patient-centered care.
Question 3 of 5
A nurse is reviewing evidence-based practice principles about administration of oxygen therapy with a newly licensed nurse. Which of the following actions should the nurse include?
Correct Answer: B
Rationale: The correct answer is B: Regulate oxygen via nasal cannula at a flow rate of no more than 6 L/min. This is the correct action because excessive oxygen flow can lead to oxygen toxicity and respiratory depression in patients. Nasal cannulas are commonly used for oxygen therapy and a flow rate of more than 6 L/min can cause discomfort and dryness of the nasal passages. It is important to adhere to evidence-based practice guidelines to ensure patient safety and well-being.
Choice A is incorrect because aligning the flow rate with the top of the ball inside the flow meter is not a reliable method for regulating oxygen flow.
Choice C is incorrect as the reservoir bag of a partial rebreathing mask should remain inflated to ensure an adequate oxygen supply.
Choice D is incorrect as petroleum jelly should not be used in oxygen therapy due to the risk of flammability.
Question 4 of 5
A nurse is caring for a client who is postoperative following a knee arthroplasty and requires the use of thigh-length sequential compression sleeves. Which of the following actions should the nurse take?
Correct Answer: C
Rationale: The correct answer is C: Make sure two fingers can fit under the sleeves. This is correct because the proper fit of sequential compression sleeves is essential for effective use. Ensuring that two fingers can fit under the sleeves ensures that they are not too tight, which could impede circulation.
Explanation for why the other choices are incorrect:
A: Assisting the client into a prone position is not necessary for applying sequential compression sleeves.
B: Placing a sleeve over the top of each leg with the opening at the knee is incorrect as the opening should be at the ankle.
D: Setting the ankle pressure at 65 mm Hg is incorrect as pressure settings should be determined based on the individual's needs and the healthcare provider's orders.
Question 5 of 5
A nurse is caring for a client who is expressing anger about his diagnosis of colorectal cancer. Which of the following actions should the nurse take?
Correct Answer: D
Rationale: The correct answer is D: Reassure the client that this is an expected response to grief. By reassuring the client that feeling anger about the diagnosis of colorectal cancer is a normal part of the grieving process, the nurse acknowledges the client's emotions and validates their experience. This can help the client feel understood and supported, fostering a therapeutic relationship. Discussing risk factors (
A) may not address the client's current emotional needs. Teaching future management (
B) may be premature as the client is currently expressing anger. Providing written information on loss and grief phases (
C) may not directly address the client's anger.
Therefore, the best immediate action is to validate the client's emotions and offer reassurance (
D).