ATI RN
ATI RN Fundamentals 2023 Questions
Extract:
Question 1 of 5
A nurse is caring for a client who has a colostomy. Which of the following actions should the nurse take?
Correct Answer: C
Rationale: The correct answer is C: Ensure the pouch is 0.32 cm (1/8 in) larger than the stoma. This is important to allow room for stoma swelling and prevent irritation.
Choice A is incorrect because rubbing the peristomal skin dry can cause skin breakdown.
Choice B is incorrect as colostomy pouches should be changed based on individual needs, not a set time frame.
Choice D is incorrect as the skin barrier should be applied to dry skin to ensure proper adhesion.
Question 2 of 5
A nurse enters the room of a client who has a seizure disorder. The client is sitting in a chair and begins to experience a seizure. Which of the following actions should the nurse take first?
Correct Answer: B
Rationale: The correct answer is B: Help the client lie on the floor. This is the first action to take during a seizure to prevent injury. By lowering the client to the floor, the risk of falling and hitting objects is minimized, ensuring safety. Turning the client onto their side (choice
A) can be done after they are on the floor to prevent aspiration. Loosening clothing (choice
C) and moving items away (choice
D) are important but secondary to ensuring the client is on the ground.
Question 3 of 5
A nurse is teaching a client how to self-administer heparin. Which of the following instructions should the nurse include in the teaching?
Correct Answer: C
Rationale: The correct answer is C: Inject 5.1 cm (2 in) away from the umbilicus. This instruction is important to prevent any damage to the abdominal organs near the umbilicus. Injecting heparin too close to the umbilicus can lead to injury or bleeding.
Choice A is incorrect because an 18-gauge, 1-inch needle is too large for subcutaneous injections like heparin administration.
Choice B is incorrect as massaging the injection site after withdrawing the needle can increase the risk of bruising or bleeding.
Choice D is incorrect as expelling air bubbles before injecting medication is essential for intravenous injections, not subcutaneous injections like heparin.
Question 4 of 5
A home health nurse is assessing the home environment of an older adult client who has osteoporosis. For which of the following findings should the nurse intervene?
Correct Answer: A
Rationale: The correct answer is A. The area rug covering a tile floor is a safety hazard for the client with osteoporosis as it increases the risk of falls. The uneven surface can cause tripping and slipping accidents, leading to fractures. The other choices are safe practices. B: Grab bars in the shower promote stability and prevent falls. C: Using a medication organizer ensures proper medication management. D: Setting the hot water heater at 47°C prevents scalding injuries.
Question 5 of 5
A nurse is caring for a client who has dysphagia and is receiving oral medications. Which of the following actions should the nurse take?
Correct Answer: D
Rationale: The correct answer is D: Administer the client's medications one at a time. This is important for a client with dysphagia to prevent choking or aspiration. Giving medications one at a time ensures the client can swallow each pill safely.
A: Assisting the client into semi-Fowler's position is generally beneficial for swallowing but is not directly related to medication administration for dysphagia.
B: Giving medications between meals may not be ideal for a client with dysphagia as they may need to take medications with food to avoid stomach upset.
C: Encouraging the use of a straw can increase the risk of aspiration for clients with dysphagia due to the potential for liquid to enter the airway.
E, F, G: Irrelevant options.