ATI RN
ATI RN Fundamentals 2023 Exam 5 Questions
Extract:
Question 1 of 5
A nurse is caring for a client who is 6 hours postoperative following abdominal surgery and is having difficulty voiding. Which of the following actions should the nurse take?
Correct Answer: D
Rationale: Allowing the client to hear running water while attempting to void can sometimes help stimulate urination through the power of suggestion. This method is non-invasive and can be effective for some patients. However, it may not be sufficient for a client who is 6 hours postoperative and experiencing significant difficulty voiding. In such cases, more direct intervention may be necessary to prevent complications like bladder distension or urinary retention. Encouraging fluid intake up to 1,000 mL daily is generally good advice for maintaining hydration and promoting urinary function. However, in the immediate postoperative period, especially within the first 6 hours, the focus should be on addressing the acute issue of urinary retention. Increasing fluid intake alone may not resolve the problem and could potentially exacerbate bladder distension if the client is unable to void. Providing the client a bedpan while lying supine is a practical approach to assist with urination, especially if the client is unable to get out of bed. However, the supine position is not the most conducive for voiding, as it can make it more difficult for the bladder to empty completely. This method might not be effective for a client experiencing significant difficulty voiding postoperatively. Inserting an indwelling urinary catheter and connecting it to gravity drainage is the most appropriate action for a client who is 6 hours postoperative and having difficulty voiding. This intervention directly addresses the issue of urinary retention by ensuring that the bladder is emptied, thereby preventing complications such as bladder distension, urinary tract infections, and potential kidney damage. It is a standard practice in postoperative care when less invasive methods are ineffective.
Question 2 of 5
A home health nurse is providing teaching about home safety to an older adult client. Which of the following examples of home safety should the nurse include in the teaching?
Correct Answer: B
Rationale: Using extension cords to prevent overloading circuits is not a recommended safety practice. Extension cords can pose tripping hazards and may not be designed to handle the electrical load of multiple devices, which can lead to overheating and potential fire risks. Obtaining a raised toilet seat for the bathroom is a practical safety measure for older adults. It helps reduce the risk of falls by making it easier for individuals with limited mobility to sit down and stand up from the toilet. This modification can significantly enhance bathroom safety. Covering slippery stairs with an area rug is not advisable. Area rugs can slip and create additional hazards. Instead, using non-slip treads or securing the rug with non-slip backing is a safer alternative. Securing loose wires under carpeting is not recommended. This practice can create a fire hazard and make it difficult to access the wires if needed. It's better to use cable management solutions that keep wires organized and out of the way without hiding them under carpeting.
Question 3 of 5
A nurse is preparing to lift a box of personal items off the floor in a client's room. Which of the following actions should the nurse take to help prevent injury when lifting the box?
Correct Answer: B
Rationale: Bending at the waist to pick up the box is not recommended as it can put excessive strain on the lower back. Proper lifting techniques involve bending at the knees and hips, not the waist, to use the stronger muscles of the legs and reduce the risk of back injury. This method helps maintain the natural curve of the spine and distributes the load more evenly. When lifting the box, keeping it close to the body is the most appropriate action. This technique reduces the lever arm distance, thereby decreasing the strain on the back muscles and spine. Holding the load close to the body ensures better control and stability, making it easier to lift and carry the box safely. Keeping the feet close together when lifting a box is not advisable. A wide stance, with feet shoulder-width apart, provides better balance and stability. This position allows for a more secure lift and reduces the risk of losing balance or straining muscles during the lifting process. Relaxing the abdominal muscles to prevent straining the back is incorrect. Engaging the core muscles, including the abdominals, provides additional support to the spine and helps maintain proper posture during lifting. Tightening the abdominal muscles can help stabilize the torso and reduce the risk of back injury.
Question 4 of 5
During change-of-shift report, a nurse discovers they overlooked a prescription for a type and cross-match of a client who is to have surgery the next day. Which of the following actions should the nurse take first?
Correct Answer: D
Rationale: Informing the provider is important but not the first step; the immediate priority is ensuring the client’s safety for surgery. Documenting the incident is necessary but secondary to addressing the clinical need. Preparing an incident report is for quality improvement and not the immediate action. Obtaining the client's type and cross-match is the first action to ensure compatible blood is available for surgery, directly addressing the oversight.
Question 5 of 5
A nurse is caring for a postoperative client. Which of the following findings indicate the client may be actively bleeding?
Correct Answer: B
Rationale: Bounding pulses are typically associated with increased cardiac output or high blood pressure, rather than active bleeding. In the context of postoperative care, bounding pulses might indicate fluid overload or other cardiovascular issues, but they are not a primary sign of active bleeding. Restlessness is a common sign of hypovolemia, which can occur due to active bleeding. When a patient is losing blood, their body may respond with anxiety or restlessness as a result of decreased oxygen delivery to tissues and organs. This is a compensatory mechanism to maintain perfusion. Restlessness, along with other signs such as tachycardia and hypotension, can indicate significant blood loss and the need for immediate intervention. Warm skin is generally not associated with active bleeding. In fact, patients who are actively bleeding may present with cool, clammy skin due to peripheral vasoconstriction as the body attempts to maintain core temperature and blood flow to vital organs. Warm skin might be observed in other conditions, such as fever or inflammation, but it is not a typical sign of active bleeding. Brisk capillary refill, which is a capillary refill time of less than 2 seconds, indicates good peripheral perfusion and is not a sign of active bleeding. In contrast, a delayed capillary refill time (greater than 2 seconds) can be a sign of poor perfusion, which might occur in the case of significant blood loss.
Therefore, brisk capillary refill is not indicative of active bleeding.