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 preparing to administer several medications via NG tube to a client who is receiving a continuous tube feeding. Which of the following actions should the nurse take?
Correct Answer: B
Rationale: The correct answer is B: Dilute each crushed medication with sterile water. This is the correct action because medications administered via NG tube should be in liquid form to prevent clogging and ensure proper absorption. Diluting each crushed medication with sterile water helps maintain the medication's consistency and facilitates its passage through the tube. Mixing medications together in a single syringe (choice
A) may cause interactions or alter the effectiveness of the medications. Flushing the NG tube with sterile water (choice
C) is important but not directly related to administering medications. Combining medications with the formula in the feeding bag (choice
D) can affect the feeding formula's composition and may lead to inaccurate dosing.
Question 3 of 5
A nurse is teaching a client who is about to undergo a bowel resection about advance directives. Which of the following instructions should the nurse include in the teaching?
Correct Answer: C
Rationale: The correct answer is C: "You will receive written information about advance directives prior to signing." This instruction is important because it ensures that the client has the necessary information to make an informed decision about advance directives. Providing written information allows the client to fully understand the purpose and implications of advance directives before signing them.
Choice A is incorrect because the provider does not need to sign the advance directives, it is the client's decision.
Choice B is incorrect as the presence of a partner is not mandatory for signing advance directives.
Choice D is incorrect as signing advance directives is a personal choice and not a requirement before surgery.
Question 4 of 5
A nurse is caring for a client who has a prescription for a 250 mL IV fluid bolus. The nurse administers a 500 mL IV bolus. Which of the following actions should the nurse take first?
Correct Answer: C
Rationale: The correct answer is C: Obtain the client's vital signs. This is the first action the nurse should take because administering a larger IV fluid bolus than prescribed can potentially lead to adverse effects such as fluid overload or electrolyte imbalances. By obtaining the client's vital signs, the nurse can assess for any immediate signs of complications, such as changes in blood pressure, heart rate, or respiratory rate. This immediate assessment is crucial in ensuring the client's safety and well-being.
Other choices are incorrect:
A: Documenting the fluid infusion is important, but not the first priority in this situation.
B: Completing an incident report should be done after addressing the immediate needs of the client.
D: Reporting the incident to the unit manager is important, but not before ensuring the client's immediate safety.
Question 5 of 5
A nurse is caring for a client following a bilateral mastectomy. The client is often tearful and avoids looking at her dressings. Which of the following actions should the nurse take first?
Correct Answer: A
Rationale: The correct answer is A: Identify the impact of the mastectomy on the client's body image. The nurse should first assess the client's emotional state and address her feelings of distress and avoidance. By identifying the impact of the mastectomy on body image, the nurse can provide emotional support and appropriate interventions. This step prioritizes the client's emotional well-being and helps establish trust. Encouraging the client to assist with dressing changes (
B) may not address the underlying emotional distress. Referring the client to a support group (
C) may be beneficial but should come after addressing the immediate emotional needs. Providing a mirror (
D) may worsen the client's distress if she is not ready to confront her incisions.