ATI RN
ATI RN Fundamentals 2023 I Questions
Extract:
Question 1 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 crucial for a client with dysphagia to prevent choking and aspiration. Providing medications separately ensures proper swallowing and minimizes the risk of medication getting stuck in the throat. Giving medications between meals (
A) may not be appropriate as it does not address the swallowing difficulty during medication administration. Assisting the client into semi-Fowler's position (
B) is generally beneficial for dysphagia but not directly related to medication administration. Encouraging the client to use a straw (
C) may further complicate the swallowing process for someone with dysphagia. Overall, administering medications one at a time is the safest and most effective approach in this situation.
Question 2 of 5
A nurse is caring for a client who is postoperative and is on bed rest. Which of the following actions should the nurse take to decrease the client’s risk of developing a pressure injury?
Correct Answer: C
Rationale: The correct answer is C: Ensure the client’s heels are not touching the mattress. This is important because pressure injuries commonly occur on bony prominences, such as the heels, due to prolonged pressure and friction. By ensuring the client’s heels are elevated off the mattress, the nurse can reduce the risk of pressure injury development in this area. Repositioning the client every 4 hours (choice
A) is important but may not specifically address the risk of pressure injury on the heels. Raising the head of the client’s bed to a 60° angle (choice
B) is more related to preventing aspiration in a postoperative client than preventing pressure injuries. Massaging the client’s bony prominences (choice
D) can actually increase the risk of skin breakdown due to friction and shearing forces.
Question 3 of 5
A nurse is planning care for a client who has a prescription for extremity restraints to both wrists. Which of the following actions should the nurse include in the plan of care? (Select all that apply.)
Correct Answer: A,B,D
Rationale:
Correct Answer: A, B, D
Rationale:
A: Ensuring the client’s bed is in the lowest position prevents falls and minimizes injury risk if the client tries to get out of bed.
B: Assessing skin temperature and color before applying restraints ensures proper circulation and skin integrity.
D: Padding bony prominences before applying restraints prevents pressure ulcers and discomfort for the client.
Summary:
C: Attaching the restraints to the bed rail can increase the risk of injury if the client moves around.
E: Allowing three fingers to slide under the restraints is incorrect as it can lead to improper fit and ineffective restraint.
Question 4 of 5
A nurse is collecting a blood pressure (BP) reading from a client who is sitting in a chair. The nurse determines that the client’s BP is 158/96 mm Hg. Which of the following actions should the nurse take?
Correct Answer: C
Rationale: The correct answer is C: Recheck the client's BP in her other arm for comparison. This is the best course of action to ensure accuracy of the BP reading. By rechecking the BP in the other arm, the nurse can determine if the initial reading was accurate or if there are any significant differences between the arms. This can help identify any potential issues such as arterial blockages or other underlying conditions affecting the BP.
Choice A is incorrect because the width of the BP cuff should be 40% of the upper arm circumference, not 50%.
Choice B is not necessary unless the client is showing signs of distress or discomfort, as it is important to keep the client in the same position for consistent readings.
Choice D is unnecessary unless there are specific reasons to suspect inaccurate readings or if the client's condition changes significantly.
In summary, rechecking the BP in the other arm is the most appropriate action to verify the accuracy of the initial reading and ensure the client's safety.
Question 5 of 5
A nurse is teaching a client about reducing the risk for osteoporosis. Which of the following statements by the client indicates an understanding of possible anaphylaxis?
Correct Answer: D
Rationale: The correct answer is D: A sharp decrease in blood pressure. This indicates an understanding of possible anaphylaxis because anaphylaxis is a severe allergic reaction that can lead to a sudden drop in blood pressure, which can be life-threatening. This symptom is crucial to recognize as it requires immediate medical attention, including the administration of epinephrine.
Choice A, B, and C do not directly relate to anaphylaxis and are more commonly associated with other conditions or reactions. By understanding the potential signs of anaphylaxis, the client can take appropriate actions to seek help promptly.