ATI RN
ATI RN Fundamentals 2023 Questions
Extract:
Question 1 of 5
A nurse is caring for a client who requires airborne precautions. The nurse is preparing to leave the client's room following a dressing change. Which of the following pieces of personal protective equipment should the nurse remove first?
Correct Answer: C
Rationale: The correct answer is C: Gloves. The nurse should remove gloves first after a dressing change to prevent contamination of other surfaces. Gloves are the primary barrier protecting the nurse from direct contact with bodily fluids. Removing gloves first helps minimize the risk of spreading pathogens. Removing eyewear, mask, or gown first could potentially expose the nurse to airborne pathogens or splash contamination. Removing the mask or gown first could also lead to contamination of the nurse's face or clothing. Removing gloves first ensures proper infection control practices are followed.
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 the client's body composition, which includes weight. Weight provides important information about the client's nutritional status and overall health. Respiratory rate (
A) is part of a vital signs assessment, not anthropometric assessment. Level of orientation (
C) and current pain level (
D) are important for assessing mental status and pain management, respectively, but they are not part of anthropometric assessment.
Question 3 of 5
A nurse manager overhears a nurse telling a client, 'I will administer your medication by injection if you don't swallow your pills.' The nurse manager should identify that the nurse is committing which of the following torts?
Correct Answer: A
Rationale: The correct answer is A: Assault. Assault is the intentional threat of harmful or offensive contact with an individual that causes reasonable apprehension of imminent contact. In this scenario, the nurse's statement of administering medication by injection if pills are not swallowed constitutes a threat of harm, leading to the client's reasonable fear of imminent bodily harm. Defamation (
B) involves false statements that harm a person's reputation, Battery (
C) is the intentional harmful or offensive contact without consent, and Invasion of privacy (
D) involves intruding on an individual's private affairs. In this case, Assault best fits the situation described.
Question 4 of 5
A nurse is planning to change a client's tracheostomy ties. Which of the following actions should the nurse take?
Correct Answer: D
Rationale:
Correct Answer: D
Rationale: Cutting the old ties after securing the new ties ensures that the client's airway remains stable throughout the procedure. If the old ties are cut before securing the new ties, there is a risk of accidental decannulation, leading to potential airway compromise. This step-by-step approach prioritizes patient safety and prevents unnecessary risks during the tracheostomy tie change.
Summary:
A: Allowing space for three fingers under the ties is important for proper fit but not the immediate action needed during the tie change.
B: Using a quick-release knot may be helpful for easy removal in emergencies but is not the primary concern during the tie change.
C: Extending the client's neck may help with visualization but is not essential for securing the ties.
D: Cutting the old ties after securing the new ties is the correct action to maintain airway stability.
E, F, G: No information provided.
Question 5 of 5
A nurse is collecting a blood pressure (BP) reading from a client who is sitting in a chair. The nurse determines that the client's BP is 158/96 mm Hg. Which of the following actions should the nurse take?
Correct Answer: B
Rationale: The correct answer is B: Recheck the client's BP in her other arm for comparison. This is the best course of action to confirm the accuracy of the initial BP reading. Taking the BP in both arms helps identify any discrepancies due to differences in blood pressure between arms or measurement errors. It also allows for better assessment of the client's overall blood pressure status.
Choice A is incorrect because the width of the BP cuff should be about 40% of the upper arm circumference, not 50%.
Choice C is inappropriate as waiting 30 minutes without immediate action can be risky if the high BP is indicative of a serious condition.
Choice D is unnecessary and may not provide additional information about the client's BP accuracy.