ATI RN
ATI RN Fundamentals 2023 Questions
Extract:
Question 1 of 5
A nurse is caring for an adolescent client who has full-thickness burns on their leg. The client expresses concern about their future. Which of the following is a therapeutic response by the nurse?
Correct Answer: C
Rationale: The correct answer is C because it acknowledges the client's feelings and shows empathy. By reflecting the client's concern about the future, the nurse validates their emotions and opens up the opportunity for further discussion and support. Option A minimizes the client's concerns, B dismisses their feelings, and D is confrontational and may make the client feel judged.
Therefore, choice C is the most therapeutic response as it promotes a trusting nurse-client relationship.
Question 2 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.
Question 3 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 4 of 5
A nurse is obtaining a health history from a client. Which of the following factors places the client at risk for cardiovascular disease?
Correct Answer: A
Rationale: The correct answer is A: Metabolic syndrome. Metabolic syndrome is a cluster of conditions that increase the risk of cardiovascular disease, including high blood pressure, high blood sugar, excess body fat around the waist, and abnormal cholesterol levels. These factors contribute to a higher likelihood of developing heart disease, stroke, and other cardiovascular issues.
Choice B, participation in competitive sports, does not inherently place a client at risk for cardiovascular disease; in fact, regular exercise is beneficial for heart health.
Choice C, family history of alcohol use disorder, may indicate a genetic predisposition to alcoholism but is not directly linked to cardiovascular disease risk.
Choice D, hypotension, is low blood pressure and is not typically associated with an increased risk of cardiovascular disease.
Question 5 of 5
A nurse is planning care for a client who has a prescription for extremity restraints to both wrists. Which of the following actions should the nurse include in the plan of care?
Correct Answer: A,C,D
Rationale: The correct actions are A, C, and D.
A: Assessing skin temperature and color before applying restraints helps prevent skin breakdown.
C: Ensuring the bed is in the lowest position reduces fall risk and injury.
D: Padding bony prominences prevents pressure injuries.
B: Attaching restraints to the bed rail can cause harm if the client moves.
E: Allowing three fingers under restraints is too loose and can lead to escape or injury.