ATI RN
ATI Nurs100102 Fundamentals Retake Questions
Extract:
Question 1 of 5
A nurse is caring for a client who has an indwelling urinary catheter and a prescription for a urine specimen for culture and sensitivity. Which of the following actions should the nurse take?
Correct Answer: A
Rationale: Withdrawing 3-5 mL ensures sufficient sample, unlike angled insertion, sterile water, or sterile gloves (clean gloves suffice).
Question 2 of 5
A nurse is caring for a client and auscultates an apical heart rate of 100/min. Which of the following actions should the nurse take?
Correct Answer: D
Rationale: A heart rate of 100/min is within normal limits, requiring documentation, not provider calls, x-rays, or verification.
Question 3 of 5
A nurse working on an orthopedic unit is caring for four clients. Which of the following clients should the nurse identify as being at greatest risk for skin breakdown?
Correct Answer: B
Rationale: Older adults in Buck's traction have fragile skin and immobility, increasing skin breakdown risk, unlike younger clients or those with less immobility.
Question 4 of 5
A nurse is caring for an older adult client. The nurse should recognize the client is at risk for which of the following physiological changes? (Select all that apply.)
Correct Answer: B,C,D
Rationale: Older adults experience higher pain thresholds, reduced skin elasticity, and slower gastric motility, not increased cardiac output or metabolism.
Question 5 of 5
The nurse is caring for a client who presented to the emergency room with BP of 138/90, HR of 110, O2 Sat of 95%, Temp of 38°C, and abdominal pain level of 7/10. Which of the above vital signs would the nurse address first?
Correct Answer: B
Rationale: Tachycardia (HR 110) indicates potential issues requiring immediate attention, unlike BP, normal O2, or mild fever.