ATI RN
ATI RN Fundamentals Updated 2023 Exam Questions
Extract:
Question 1 of 5
A nurse is caring for a client following a bilateral mastectomy. The client is often tearful and avoids looking at her dressings. Which of the following actions should the nurse take first?
Correct Answer: A
Rationale: The correct answer is A: Identify the impact of the mastectomy on the client's body image. The nurse should first assess the client's emotional state and address her feelings of distress and avoidance. By identifying the impact of the mastectomy on body image, the nurse can provide emotional support and appropriate interventions. This step prioritizes the client's emotional well-being and helps establish trust. Encouraging the client to assist with dressing changes (
B) may not address the underlying emotional distress. Referring the client to a support group (
C) may be beneficial but should come after addressing the immediate emotional needs. Providing a mirror (
D) may worsen the client's distress if she is not ready to confront her incisions.
Question 2 of 5
A nurse is discussing the stages of general adaptation syndrome with a newly licensed nurse. The nurse should identify that which of the following manifestations occurs during the alarm reaction stage?
Correct Answer: A
Rationale: During the alarm reaction stage of general adaptation syndrome, the body responds to stress by activating the fight-or-flight response. Dilated pupils occur as part of this response to enhance visual acuity and peripheral vision, preparing the individual for potential threats. This physiological change helps the person to be more aware and ready to react quickly in a stressful situation.
Choices B, C, and D are incorrect because physical exhaustion, bradycardia (slow heart rate), and depression are manifestations that are not typically associated with the alarm reaction stage. Physical exhaustion may occur in the exhaustion stage, bradycardia is not a typical response to stress, and depression is a psychological response that may occur in the resistance or exhaustion stages.
Question 3 of 5
A nurse is preparing a sterile field to assist with suturing a client's laceration. Which of the following actions should the nurse plan to take?
Correct Answer: C
Rationale: The correct answer is C: Hold the bottle of sterile solution so that the label is facing the palm of the hand. This action is important to maintain the sterility of the solution. By holding the bottle with the label facing the palm, the nurse ensures that the solution does not come into contact with the outside of the bottle, which could introduce contaminants. This practice helps prevent the introduction of microorganisms into the sterile field, reducing the risk of infection for the client.
Incorrect options:
A: Applying sterile gloves before opening the bottle of sterile solution is not necessary for preparing the sterile field.
B: Placing the lid of the sterile solution bottle face down on the sterile drape can lead to contamination.
D: Pouring the sterile solution from a height of 20 cm (8 in) above the sterile bowl may create splashing and increase the risk of contamination.
Question 4 of 5
A nurse is preparing to administer IV fluids to a client. The nurse notes sparks when plugging in the IV pump. Which of the following actions should the nurse take first?
Correct Answer: A
Rationale:
Correct
Answer: A - Unplug the pump
Rationale: The sparks indicate an electrical issue with the pump, posing a safety hazard. Unplugging the pump immediately is crucial to prevent any potential harm to the client or staff. This action prioritizes safety and addresses the immediate risk.
Incorrect choices:
B: Labeling the pump with a defective equipment sticker does not address the immediate safety concern of the sparks. It is important to prioritize safety first.
C: Obtaining a replacement pump is not necessary until the safety issue is resolved with the current pump.
D: Notifying the biomedical department is important, but the immediate action should be to unplug the pump to prevent any potential harm.
Question 5 of 5
A nurse is assessing a client who has diabetes mellitus prior to performing a blood glucose test. Which of the following findings should indicate to the nurse that the client has hyperglycemia?
Correct Answer: B
Rationale: The correct answer is B: Thirst. Hyperglycemia leads to increased glucose levels in the blood, causing the body to try to dilute the sugar by increasing urination, leading to dehydration and thirst. Confusion (
A) can indicate hypoglycemia, not hyperglycemia. Cold skin (
C) and shakiness (
D) are not specific signs of hyperglycemia.