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 correct because the proper fit of sequential compression sleeves is essential for effective use. Ensuring that two fingers can fit under the sleeves ensures that they are not too tight, which could impede circulation.
Explanation for why the other choices are incorrect:
A: Assisting the client into a prone position is not necessary for applying sequential compression sleeves.
B: Placing a sleeve over the top of each leg with the opening at the knee is incorrect as the opening should be at the ankle.
D: Setting the ankle pressure at 65 mm Hg is incorrect as pressure settings should be determined based on the individual's needs and the healthcare provider's orders.
Question 2 of 5
A nurse is caring for a client who is expressing anger about his diagnosis of colorectal cancer. Which of the following actions should the nurse take?
Correct Answer: D
Rationale: The correct answer is D: Reassure the client that this is an expected response to grief. By reassuring the client that feeling anger about the diagnosis of colorectal cancer is a normal part of the grieving process, the nurse acknowledges the client's emotions and validates their experience. This can help the client feel understood and supported, fostering a therapeutic relationship. Discussing risk factors (
A) may not address the client's current emotional needs. Teaching future management (
B) may be premature as the client is currently expressing anger. Providing written information on loss and grief phases (
C) may not directly address the client's anger.
Therefore, the best immediate action is to validate the client's emotions and offer reassurance (
D).
Question 3 of 5
A nurse is responding to a call light and finds a client lying on the bathroom floor. Which of the following actions should the nurse take first?
Correct Answer: A
Rationale: The correct action is to check the client for injuries first because ensuring the client's immediate safety and well-being is the top priority. By assessing for injuries, the nurse can determine the severity of the situation and provide necessary interventions promptly. Moving hazardous objects (
B) can wait until after ensuring the client's safety. Notifying the provider (
C) can also be done after assessing the client's condition. Asking the client to describe how she felt prior to the fall (
D) is important for gathering information but is not as urgent as checking for injuries.
Question 4 of 5
A nurse is caring for a client who is postoperative and refuses to use an incentive spirometer following major abdominal surgery. Which of the following actions is the nurse's priority?
Correct Answer: B
Rationale: The correct answer is B: Determine the reasons why the client is refusing to use the incentive spirometer. The priority is to assess the client's reasons for refusal to address any barriers preventing compliance, such as fear, pain, or lack of understanding. Understanding the client's perspective can help tailor interventions and address concerns effectively. Requesting a respiratory therapist (choice
A) or administering pain medication (choice
D) can be secondary once the client's reasons are identified. Simply documenting the refusal (choice
C) without addressing the underlying cause does not promote client-centered care.
Extract:
Nurses' Notes
1100: Client reports fever, chills, cough, and night sweats for past 2 weeks. Client has recently traveled outside of the country. Lethargic, but oriented to person, place, and time. Crackles heard in lower lobes of lungs upon auscultation. Cough is productive with small amounts of blood. Reports tightness in chest and pain when coughing. Reports losing 5 Ib in the last week. Has no appetite and is nauseated. Obtained blood work, chest x-ray, and sputum cult
Question 5 of 5
The nurse is placing the client on isolation precautions. Which of the following interventions should the nurse include? Select all that apply.
Correct Answer: B
Rationale: The correct answer is B: Place a container for soiled linens inside the client's room. This intervention is important to prevent the spread of infection. Placing a container for soiled linens inside the client's room ensures that contaminated linens are contained and not mixed with other linens, reducing the risk of transmitting the infection to others.
Rationale for why other choices are incorrect:
A: Wearing an N95 mask is not necessary unless the client has airborne precautions, such as tuberculosis.
C: Placing the client in a negative airflow room is typically reserved for clients with airborne infections to prevent the spread of droplet nuclei in the air.
D: Removing the mask after exiting the client's room is incorrect as the mask should be removed before exiting to prevent contamination outside the room.
In summary, choice B is correct as it directly addresses infection control measures related to soiled linens, while the other choices are not relevant to isolation precautions or are incorrect based on standard