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.
Extract:
Nurses' Notes
Day 1, 1100:
• Temperature 39.1° C (102.4° F)
• Pulse rate 102/min
• Respiratory rate 26/min
• Blood pressure 122/80 mm Hg
• Oxygen saturation 86% on room air
• Weight 90.7 kg (200 lb)
Day 2, 1200:
• Temperature 38° C (100.4" F)
• Pulse rate 100/min
• Respiratory rate 22/min
• Blood pressure 120/74 mm Hg
• Oxygen saturation 88% on nasal cannula at 2 L/min
Day 3, 1200:
• Temperature 37.2° C (98.9" F)
• Pulse rate 90/min
• Respiratory rate 20/min
• Blood pressure 120/72 mm Hg
• Oxygen saturation 91% on nasal cannula at 3 L/min
Day 4, 1500:
• Temperature 37.2° C (98.9° F)
• Pulse rate 92/min
• Respiratory rate 22/min
• Blood pressure 120/72 mm Hg
• Oxygen saturation 93% on nasal cannula at 3 L/min: 88% on room air
Vital Signs
Day 1, 1100:
• Temperature 39.1° C (102.4° F)
• Pulse rate 102/min
• Respiratory rate 26/min
• Blood pressure 122/80 mm Hg
• Oxygen saturation 86% on room air
• Weight 90.7 kg (200 lb)
Day 2, 1200:
• Temperature 38° C (100.4" F)
• Pulse rate 100/min
• Respiratory rate 22/min
• Blood pressure 120/74 mm Hg
• Oxygen saturation 88% on nasal cannula at 2 L/min
Day 3, 1200:
• Temperature 37.2° C (98.9" F)
• Pulse rate 90/min
• Respiratory rate 20/min
• Blood pressure 120/72 mm Hg
• Oxygen saturation 91% on nasal cannula at 3 L/min
Day 4, 1500:
• Temperature 37.2° C (98.9° F)
• Pulse rate 92/min
• Respiratory rate 22/min
• Blood pressure 120/72 mm Hg
• Oxygen saturation 93% on nasal cannula at 3 L/min: 88% on room air
Medication Administration Record
Day 1, 1500:
• Cefazolin 500 mg every 12 hr IV Dexamethasone 15 mg every 6 hr IV
Day 3, 1200:
• Discontinue dexamethasone 15 mg every 6 hr IV Prednisone 40 mg PO daily
Day 4, 1500:
• Discontinue cefazolin 500 mg every 12 hr IV
Question 2 of 5
A nurse is providing discharge teaching for the client and their caregiver. Which of the following information should the nurse include?
Correct Answer: A,C
Rationale: The correct answers are A and C. Option A is important as adjusting oxygen flow rate can help ease breathing, ensuring optimal oxygen delivery. Option C advises storing the oxygen cylinder wrench with the tank for easy access in case of emergencies. These two pieces of information are crucial for maintaining proper oxygen therapy and ensuring safety.
Options B, E, F, and G are incorrect. Option B states a specific duration for antibiotic therapy, which may vary depending on the type of infection. Option E relates to steroid medication administration timing, which can vary based on the specific medication and condition. Option F provides general advice on antibiotic administration but may not apply to all antibiotics. Option G implies a specific tapering schedule for steroids, which should be individualized based on the patient's condition and response.
Extract:
Diagnostic Results
1000:
• Prealbumin level 13 mg/dL (15 to 36 mg/dL)
• Cholesterol 210 mg/dL (less than 200 mg/dL)
• Fasting glucose 110 mg/dL (70 to 110 mg/dL)
Medical History
0800:
The client has a history of malnutrition, hyperlipidemia, and diabetes mellitus. Mini Nutritional Assessment screening tool score of 7 points (0 to 14 points)
Question 3 of 5
A nurse is caring for a client who is scheduled for surgery. Exhibits The nurse is reviewing the client's medical record. Which of the following findings places the client at risk for delayed wound healing? Select all that apply.
Correct Answer: C,D,F
Rationale:
Correct
Answer: C, D, F
Rationale:
C: History of malnutrition - Malnutrition leads to a deficiency in essential nutrients needed for wound healing, impairing the body's ability to repair tissues.
D: History of diabetes mellitus - Diabetes can lead to impaired circulation and nerve damage, both of which can delay wound healing.
F: Prealbumin level - Prealbumin is a marker of protein status and low levels indicate poor nutritional status, which can impact wound healing.
Incorrect
Choices:
A: Mini Nutritional Assessment screening tool score - While this tool assesses nutritional status, it does not directly indicate a risk for delayed wound healing.
B: History of hyperlipidemia - Hyperlipidemia is elevated levels of lipids in the blood and is not directly related to delayed wound healing.
E: Cholesterol level - Cholesterol level alone does not necessarily correlate with delayed wound healing risk.
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:
A nurse is caring for a client.
Vital Signs
0800:
Temperature 37.6° C (99.7 F) Blood pressure 108/56 mm Hg Heart rate 66/min Respiratory rate 18/min
Pulse oximetry 97% on room air 0830:
Temperature 37.5° C (99.5° F) Blood pressure 88/56 mm Hg Heart rate 104/min Respiratory rate 24/min
Pulse oximetry 93% on room air Nurses' Notes
0800:
Antibiotic administered as prescribed.
Bilateral breath sounds clear and present throughout. 0830
Client reports itching over the chest area and has urticaria over chest and trunk.
Client states tongue feels swollen
Question 5 of 5
Bilateral breath sounds with scattered wheezing upon auscultation, Select the 4 findings that require immediate follow-up.
Correct Answer: B,D,E,F
Rationale: The correct answer is B, D, E, and F. Monitoring blood pressure (
B) is crucial to assess for potential respiratory distress. Urticaria (
D) indicates a possible allergic reaction requiring immediate attention. Swollen tongue (E) can be a sign of angioedema, a severe allergic reaction affecting the airway. Bilateral breath sounds with wheezing (F) suggest respiratory compromise requiring prompt intervention. Heart rate (
A) and temperature (
C) are important but not as urgent in this scenario.