ATI RN
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ATI RN Fundamentals Exam 6 Questions
Extract:
Question
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1 of 5
A nurse is caring for a client who had a cerebrovascular accident and is at risk for falls. The nurse should recognize that which of the following is an appropriate safety precaution?
Correct Answer: A
Rationale: Monitoring the client at least once every hour is an appropriate safety precaution to assess the client's condition and prevent falls. Assigning the client to a private room may not directly address the risk of falls and may not be necessary for fall prevention. Requesting a PRN prescription for restraints should not be the first line of defense for fall prevention and should only be considered when other interventions are ineffective or inappropriate. Keeping four side rails up while the client is in bed can be a restraint and may increase the risk of injury. It is not a recommended approach for fall prevention.
Question 2 of 5
A nurse is planning care for an older adult client who has urinary incontinence. Which of the following interventions should the nurse include in the client's plan of care?
Correct Answer: A
Rationale: Applying a moisture barrier helps protect the skin from irritation and breakdown due to prolonged exposure to moisture. Cleansing the skin with antibacterial soap and hot water may be too harsh and can contribute to skin irritation; gentle cleaning with a mild cleanser is preferable.
Toileting the client every 4 hours may not be frequent enough to prevent skin breakdown; a more frequent toileting schedule should be implemented. Reducing the client's daily fluid intake is not a recommended intervention for urinary incontinence as it may lead to dehydration and other health issues.
Question 3 of 5
A 5-year-old client is refusing to let the nurse take his blood pressure. To promote cooperation the nurse should:
Correct Answer: C
Rationale: Telling the child that it will not hurt may not be effective as children may still have anxiety or fear related to the unknown. Forcing a child or having the parent hold tightly may increase anxiety and make the child more resistant to the procedure. Allowing the child to operate the equipment can give the child a sense of control and involvement increasing cooperation. Deferring the procedure until the next visit may not be practical or necessary if alternative strategies can be employed to promote cooperation.
Question 4 of 5
A nurse is delegating obtaining the collection of a client's oral temperature to an assistive personnel (AP). The nurse notes in the documentation that the AP obtained the client's axillary temperature. Which of the following rights of delegation should have prevented this situation from occurring?
Correct Answer: A
Rationale: The right task involves ensuring that the delegated task is appropriate for delegation. In this case obtaining an oral temperature should have been the correct task; however the AP performed the axillary temperature indicating a deviation from the right task. Right communication involves clear and effective communication between the nurse and the assistive personnel but is not directly related to the task performed. Right person involves ensuring that the task is delegated to a competent and qualified individual. The issue in this scenario is with the task itself not the competency of the individual. Right circumstance involves ensuring that the conditions are appropriate for delegation. While the circumstance is important the primary concern in this case is the mismatch between the task and the method of temperature measurement.
Question 5 of 5
A nurse is providing care for a client who is scheduled for a total laryngectomy. Which of the following is the nurse's priority intervention?
Correct Answer: D
Rationale: Showing the client how to use an artificial larynx is an important aspect of post-laryngectomy care but determining the client's reading ability takes precedence as it will significantly impact communication options. Arranging a support session is important for emotional support but assessing the client's reading ability is more immediate in addressing communication needs. Demonstrating the use of esophageal speech is relevant but understanding the client's reading ability is a priority before exploring communication alternatives.