ATI RN
ATI RN Fundamentals 2023 II 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: A
Rationale:
Correct
Answer: A - Ensure the client's heels are not touching the mattress.
Rationale:
1. Pressure injuries commonly occur at bony prominences like heels.
2. When heels are in contact with the mattress for a prolonged period, it can lead to compromised blood flow and tissue damage.
3. Elevating the heels off the mattress reduces pressure and friction, decreasing the risk of pressure injury.
Summary of other choices:
B. Repositioning every 4 hr helps prevent pressure injuries but focusing on heel offloading is more critical.
C. Raising the head of the bed does not directly address the pressure on the heels.
D. Massaging bony prominences can actually increase the risk of pressure injury by causing friction and shearing forces.
Question 2 of 5
A nurse is preparing to perform an anthropometric assessment on a client. Which of the following client data should the nurse include?
Correct Answer: B
Rationale: The correct answer is B: Weight. Anthropometric assessment involves measuring body weight as part of evaluating a client's overall health status. Weight provides valuable information about a client's nutritional status, growth, and potential health risks. Respiratory rate (
A) is part of a vital signs assessment, not anthropometric assessment. Level of orientation (
C) pertains to mental status evaluation. Current pain level (
D) is important for assessing discomfort but is not part of anthropometric assessment.
Question 3 of 5
A nurse is caring for a client who reports that she has insomnia. Which of the following interventions is appropriate for the nurse to recommend?
Correct Answer: C
Rationale: The correct answer is C: Eat a light carbohydrate snack before bedtime. Carbohydrates can increase the production of serotonin, a neurotransmitter that helps regulate sleep. This can promote relaxation and aid in falling asleep. Napping during the day (choice
A) can make it harder to sleep at night. Exercising close to bedtime (choice
B) can increase alertness and make it difficult to fall asleep. Drinking hot cocoa (choice
D) can also contain caffeine, which can disrupt sleep.
Question 4 of 5
A nurse is caring for a client who has severe rheumatoid arthritis in her hands and is unable to feed herself. For which of the following health care team members should the nurse request a referral from the provider?
Correct Answer: D
Rationale: The correct answer is D: Occupational therapist. An occupational therapist specializes in helping individuals regain independence in performing daily activities, such as feeding themselves. They can provide adaptive tools and techniques to assist the client with severe rheumatoid arthritis in her hands. A social worker (
A) typically focuses on psychosocial issues, a physician assistant (
B) assists the physician in medical care, and a physical therapist (
C) focuses on physical rehabilitation.
Therefore, the best choice for this scenario is an occupational therapist.
Question 5 of 5
A nurse is preparing to administer packed RBCs to a client who has a low hemoglobin level. Which of the following actions should the nurse take prior to the start of the infusion?
Correct Answer: A
Rationale: The correct answer is A: Check the blood product's compatibility with the client's blood type. This is crucial to prevent a potentially life-threatening transfusion reaction. The nurse must verify that the blood product matches the client's blood type to avoid hemolysis. Checking for compatibility ensures that the client's immune system will not attack the transfused blood cells.
Choices B, C, and D are incorrect:
B: Checking for a small gauge IV catheter is important for administering blood products, but it is not the priority before the start of the infusion.
C: Confirming the client's identity with the blood bank technician is essential but does not directly relate to the safety of the transfusion.
D: Priming the IV tubing with lactated Ringer's is not necessary as the packed RBCs should be administered with a separate tubing set to prevent any potential interactions.