ATI RN
ATI RN Fundamentals Updated 2023 Exam Questions
Extract:
Question 1 of 5
A nurse is caring for a client who has restraints to each extremity. Which of the following assessments should the nurse perform first?
Correct Answer: B
Rationale: The correct assessment the nurse should perform first is B: Peripheral pulses. Monitoring peripheral pulses is crucial when a client is restrained to detect any signs of compromised circulation. This assessment takes priority over the other options because impaired circulation can lead to serious complications such as tissue damage or even limb loss. Assessing skin integrity, comfort level, and elimination needs are important tasks but can wait until after ensuring adequate circulation. Checking peripheral pulses is the initial step to ensure the client's safety and prevent potential harm.
Question 2 of 5
A nurse is caring for a client who is receiving continuous enteral feeding via NG tube. Which of the following is an unexpected finding?
Correct Answer: D
Rationale: The correct answer is D: A gastric residual of 300 mL at the end of the shift. This finding is unexpected because a high residual volume may indicate feeding intolerance or delayed gastric emptying, which can lead to aspiration or other complications. Monitoring gastric residuals helps assess the client's tolerance to enteral feeding.
A: A weight gain of 0.91 kg (2 lb) in 2 days - This could be expected due to fluid retention or intake exceeding output.
B: A blood glucose level of 110 mg/dL - This is within normal range and not unexpected.
C: Diarrhea one time in a 24-hr period - Occasional diarrhea can occur with enteral feeding and is not necessarily unexpected.
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 community health nurse is teaching a group of clients about Kegel exercises to prevent urinary incontinence. Which of the following instructions should the nurse include?
Correct Answer: B
Rationale: The correct answer is B: Contract your pelvic muscle when performing the exercises. Kegel exercises aim to strengthen the pelvic floor muscles, which support the bladder and bowel functions. Contracting the pelvic muscles during these exercises helps to improve control over urinary incontinence. Holding your breath (
A) is not recommended as it can increase intra-abdominal pressure. Expecting improvement after 2 weeks (
C) is not accurate; it may take longer to see results. Tightening the buttocks (
D) does not target the pelvic muscles effectively.
Question 5 of 5
A nurse is caring for a client who is 2 days postoperative following bowel resection and reports sudden, severe abdominal pain. Which of the following actions should the nurse take first?
Correct Answer: D
Rationale: The correct answer is D: Expose the client's abdomen to look for changes in appearance. This action should be taken first because sudden, severe abdominal pain postoperatively can indicate a serious complication like internal bleeding or bowel perforation. By exposing the abdomen, the nurse can visually assess for signs of distention, discoloration, or any other abnormality that may indicate a surgical complication. This visual assessment can provide crucial information to guide further interventions.
Choices A, B, and C involve assessment techniques that may be important in evaluating the client's condition, but they should be secondary to visually inspecting the abdomen in this urgent situation.
Choice A focuses on bowel sounds, which may not be reliable in a postoperative client experiencing sudden severe pain.
Choice B involves palpation, which could potentially exacerbate any existing complications.
Choice C refers to assessing areas of resonance, which is less urgent compared to visually inspecting for immediate changes in the abdomen.
In summary, visually inspecting the client's