ATI RN
ATI RN Fundamentals 2023 Questions
Extract:
Question 1 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: B
Rationale:
Correct Answer: B - Ensure the client's heels are not touching the mattress.
Rationale: Keeping the client's heels off the mattress reduces pressure on this vulnerable area, decreasing the risk of developing pressure injuries. Pressure injuries commonly occur on bony prominences like the heels, making option A incorrect. Raising the head of the bed does not directly address pressure injury prevention, so option C is not the best choice. Repositioning every 4 hours is important but may not be sufficient to prevent pressure injuries, making option D less effective than ensuring the heels are off the mattress.
Question 2 of 5
A nurse in an emergency department is caring for a client who is unconscious and requires surgery. There is no one available to give consent for the treatment. Which of the following actions should the nurse take?
Correct Answer: A
Rationale: The correct answer is A: Prepare the client for surgery. In an emergency situation where the client is unconscious and no one is available to give consent, the nurse must act in the best interest of the client. This includes providing necessary and life-saving treatment without delay. Delaying surgery to wait for consent may jeopardize the client's health and violate the principle of beneficence. Contacting the ethics committee (
B) may cause further delay, and keeping the client stable until a family member arrives (
C) may not be feasible in urgent cases. Obtaining consent from the surgeon (
D) is not ethically appropriate as the surgeon cannot provide consent on behalf of the client.
Question 3 of 5
A nurse is planning care for a client who is immobile. Which of the following actions should the nurse include in the plan of care?
Correct Answer: B
Rationale: The correct answer is B: Use trochanter rolls beside the client's legs. Trochanter rolls help maintain proper alignment of the hips and prevent external rotation of the legs, reducing the risk of pressure ulcers and hip dislocation. Logrolling (choice
A) is not necessary unless specifically indicated for spinal precautions. Placing the client's arms at their side (choice
C) may restrict circulation and lead to discomfort. Crossing the client's ankles (choice
D) could cause pressure ulcers and impair circulation.
Extract:
Medical History
Initial visit:
Client reports a sedentary lifestyle.
Client is lactose intolerant and denies taking vitamin supplements. Client is a nonsmoker.
Client does not drink alcohol.
Diagnostic Results
Initial visit:
• Calcium 8.9 mg/dL (9 to 10.5 mg/dL)
• Phosphorus 3.4 mg/dL (3 to 4.5 mg/dL)
• Total 25-hydroxy D (vitamin D2+ D3) 24 ng/dL (25 to 80 ng/dL)
6-month follow-up:
• Calcium 8.8 mg/dL (9 to 10.5 mg/dL)
• Phosphorus 3.2 mg/dL (3 to 4.5 mg/dL)
• Total 25-hydroxy D (vitamin D2+D) 15 ng/dL (25 to 80 ng/dL)
Nurses' Notes
Initial visit:
Client instructed to take a calcium and vitamin D supplement and begin an exercise program, such as walking 3 times per week.
6-month follow-up:
Client states they frequently forget to take their calcium and vitamin D supplements and has been unable to exercise due to time constraints.
Question 4 of 5
A nurse in a provider's office is caring for a client. Exhibits:The nurse is reviewing the client's medical record. Which of the following findings places the client at risk for osteoporosis? (Select all that apply.)
Correct Answer: C,F
Rationale: The correct answers are C: Vitamin D level and F: Activity level. Low levels of Vitamin D can lead to decreased calcium absorption, which is essential for bone health, increasing the risk of osteoporosis. A sedentary lifestyle or low activity level can also contribute to bone loss and weaken bones, further predisposing the client to osteoporosis.
Incorrect answers:
A: Lactose intolerance does not directly increase the risk of osteoporosis unless it leads to significant calcium deficiency.
B: Smoking is a risk factor for osteoporosis, but it is not listed as an option in this question.
D: Phosphorus levels are not typically used as a direct indicator of osteoporosis risk.
E: While excessive alcohol consumption can negatively impact bone health, it is not listed as a risk factor in this question.
Extract:
Question 5 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?
Correct Answer: A,C,D
Rationale: The correct actions are A, C, and D.
A: Assessing skin temperature and color before applying restraints helps prevent skin breakdown.
C: Ensuring the bed is in the lowest position reduces fall risk and injury.
D: Padding bony prominences prevents pressure injuries.
B: Attaching restraints to the bed rail can cause harm if the client moves.
E: Allowing three fingers under restraints is too loose and can lead to escape or injury.