ATI RN
RN-ATI-Fundamentals-of-Nursing-2023-2024 Questions
Extract:
Question 1 of 5
A nurse is caring for a client who is postoperative following a knee arthroplasty and requires the use of thigh-length sequential compression sleeves. Which of the following actions should the nurse take?
Correct Answer: C
Rationale: The correct answer is C: Make sure two fingers can fit under the sleeves. This is important to ensure proper circulation and prevent undue pressure on the client's legs. If the sleeves are too tight, it can lead to decreased blood flow and potential complications like deep vein thrombosis.
Choice A is incorrect because placing the client in a prone position is not necessary for using sequential compression sleeves.
Choice B is incorrect as the opening of the sleeve should be at the foot, not the knee.
Choice D is incorrect as the ankle pressure should typically be set according to the specific manufacturer's guidelines, not a fixed value of 65 mm Hg.
Question 2 of 5
A nurse is assessing a client immediately following a cardiac catheterization. The nurse should notify the provider for which of the following findings?
Correct Answer: C
Rationale: The correct answer is C: Bounding pulses in the affected extremity. This finding could indicate arterial occlusion, a serious complication post-cardiac catheterization that requires immediate intervention to prevent tissue damage or loss of limb. Discomfort at the insertion site (
A) is expected and can be managed with analgesics. Heart rate of 90/min (
B) is within normal range. Hematoma over the insertion site (
D) is a common minor complication that may resolve on its own.
Question 3 of 5
A nurse is assisting with the care of a client who has a prescription for IV therapy. The client tells the nurse that he has numerous allergies. Which of the following allergies should the nurse bring to the attention of the charge nurse prior to the initiation of the therapy?
Correct Answer: A
Rationale: The correct answer is A: Latex. Latex allergies are crucial to address prior to IV therapy as latex is commonly found in medical equipment like gloves and IV tubing. An allergic reaction to latex can be severe and life-threatening. Seafood, bee stings, and peanuts are not typically related to IV therapy and would not directly impact the administration of the therapy. The focus should be on latex allergy due to its direct relevance to medical equipment used during IV therapy.
Question 4 of 5
A nurse has just received change-of-shift report for four clients. Which of the following clients should the nurse assess first?
Correct Answer: C
Rationale: The correct answer is C. The nurse should assess the client who was just given a glass of orange juice for a low blood glucose level first because hypoglycemia can lead to serious complications such as seizures or loss of consciousness. Assessing this client first allows the nurse to monitor for signs of worsening hypoglycemia and take prompt action if needed.
Choice A is incorrect because a client scheduled for a procedure in 1 hr can be assessed after ensuring the immediate safety of the client with low blood glucose.
Choice B is incorrect since a client who received pain medication 30 min ago for postoperative pain doesn't indicate an immediate life-threatening situation.
Choice D is incorrect as a client with 100 mL of fluid remaining in the IV bag can be monitored but doesn't require immediate attention compared to a client with low blood glucose levels.
Question 5 of 5
A nurse is setting up a sterile field to perform wound irrigation for a client. Which of the following actions should the nurse take when pouring the sterile solution?
Correct Answer: A
Rationale: The correct answer is A because removing the cap and placing it sterile-side up on a clean surface helps maintain the sterility of the solution. Placing the cap sterile-side up prevents contamination of the inside of the cap. This action ensures that the contents of the bottle remain sterile while allowing easy access to the solution during the procedure.
In contrast, option B is incorrect because placing sterile gauze over spilled solution within the sterile field may introduce non-sterile material into the field. Option C is incorrect as holding the bottle in the center of the sterile field may increase the risk of accidental contamination. Option D is incorrect because holding the irrigation solution bottle with the label facing away from the palm of the hand does not ensure the sterility of the solution.