ATI RN
ATI RN Fundamentals Updated 2023 Exam Questions
Extract:
Question 1 of 5
A nurse is caring for a client who has wrist restraints after an episode of violent behavior. Which of the following actions should the nurse take?
Correct Answer: B
Rationale: The correct answer is B. Removing one restraint at a time allows for gradual release of restraint pressure, preventing sudden movement that could result in injury. Tying restraints to the side rail (
A) increases risk of injury. Securing restraints with a square knot (
C) may be difficult to untie quickly in an emergency. Removing restraints every 3 hours (
D) does not address the immediate need for safety.
Question 2 of 5
A nurse is assessing an older adult client. Which of the following findings should the nurse expect?
Correct Answer: B
Rationale: The correct answer is B: Decreased sense of balance. As people age, their sense of balance tends to decrease due to changes in vision, inner ear function, muscle strength, and joint flexibility. This can increase the risk of falls and injuries in older adults. The other choices are incorrect because heightened sense of pain (
A) is not a typical finding in older adults, increased nighttime sleeping (
C) may occur but it is not a universal finding, and nighttime urinary incontinence (
D) is common but not a definitive finding in all older adults.
Question 3 of 5
A nurse in an emergency department is assessing a client who reports right lower quadrant pain, nausea, and vomiting for the past 48 hr. Which of the following actions should the nurse take first?
Correct Answer: D
Rationale: The correct answer is D: Auscultate bowel sounds. This is the first action the nurse should take as it can provide crucial information about the client's condition, particularly in suspected appendicitis. Absence of bowel sounds in the right lower quadrant may indicate an inflamed appendix, requiring immediate medical attention. Administering an antiemetic (choice
A) or pain medication (choice
B) without assessing the bowel sounds first could mask important symptoms. Palpating the abdomen (choice
C) can potentially worsen the client's condition if appendicitis is present.
Therefore, auscultating bowel sounds is the priority to guide further assessment and intervention.
Question 4 of 5
A nurse is preparing to administer a medication to a client. Which of the following should the nurse use as a client identifier?
Correct Answer: A
Rationale: The correct answer is A: Name. The nurse should use the client's name as the identifier because it is a unique and specific way to confirm the client's identity. Names are individualized and less likely to be shared among patients, reducing the risk of medication errors. Using age (
B), photograph (
C), room number (
D), or bed number (E) alone may not guarantee accurate identification. Age, photographs, room numbers, and bed numbers can be shared or mistaken, leading to potential errors. Using the client's name ensures proper identification and enhances patient safety.
Question 5 of 5
A nurse is performing postural drainage with percussion and vibration for a client who has cystic fibrosis. Which of the following actions should the nurse take?
Correct Answer: B
Rationale: The correct answer is B: Cover the area of percussion with a towel. This is important to prevent skin irritation or discomfort during the procedure. The towel acts as a barrier between the client's skin and the nurse's hand, reducing friction and protecting the skin. Performing percussion directly on the skin can cause redness, bruising, or discomfort, so covering the area with a towel is a standard practice to ensure the client's safety and comfort.
Choice A is incorrect because percussion should be performed over specific areas of the chest, not the lower back.
Choice C is incorrect as postural drainage should be scheduled before meals to prevent aspiration.
Choice D is incorrect as clients should exhale slowly and relax during vibration to promote airway clearance.