ATI RN
ATI Fundamentals 2023 Retake Questions
Extract:
Question 1 of 5
A nurse is caring for an older adult client who has significant issues with ascites related to end-stage liver disease. Which of the following precautions is most important for the nurse to include in the teaching?
Correct Answer: C
Rationale: The correct answer is C. Due to the increased abdominal weight from ascites, the client should take their time with walking as their balance might be affected, potentially leading to a fall. This is crucial because older adults with ascites are at higher risk of falls due to the increased abdominal girth affecting their center of gravity and balance. By taking precautions and walking slowly, the client can reduce the risk of injury.
Choices A, B, and D are incorrect:
A: Having extra pillows in bed for comfort is important, but it does not address the immediate safety concern of potential falls due to impaired balance.
B: Advising the client not to wear undergarments due to abdominal weight is not necessary for fall prevention and may not be practical or comfortable for the client.
D: Restricting exercise completely is not ideal, as some forms of physical activity may still be beneficial for the client's overall health, as long as they are done safely.
Question 2 of 5
A nurse is preparing to set up a sterile field. Which of the following actions should the nurse take?
Correct Answer: B
Rationale: The correct answer is B: Hold bottles of sterile solution with the label in the palm of the hand. This is important to maintain sterility as it prevents contamination from the label touching non-sterile surfaces. Holding the bottle in the palm of the hand also helps prevent accidental spills.
Choice A is incorrect because opening the outermost flap of the sterile kit toward the body can cause contamination.
Choice C is incorrect as pouring liquids into containers outside the sterile field can introduce contaminants.
Choice D is incorrect because placing the sterile field at the level of the nurse's hips can increase the risk of contamination from the nurse's clothing.
Question 3 of 5
How will the nurse assess for flank tenderness in a patient with suspected pyelonephritis?
Correct Answer: D
Rationale: The correct answer is D: Strike a flat hand covering the costovertebral angle (CV
A). This method is known as CVA tenderness test and is used to assess for flank tenderness specifically related to kidney inflammation like pyelonephritis. By striking the CVA, the nurse can elicit pain or tenderness in the affected kidney area. Percussing between the iliac crest and ribs (
A) is used to assess for liver size. Pushing fingers upward into the intercostal spaces (
B) is done to assess for splenomegaly. Palpating along the lumbar vertebral column (
C) is not specific for flank tenderness related to pyelonephritis.
Question 4 of 5
A nurse in a mental health clinic is caring for an older adult client who has depression and has stopped taking their medication. The client tells the nurse, 'I want to die now that my partner is gone.' Which of the following responses should the nurse make?
Correct Answer: B
Rationale: Answer B is correct because it directly addresses the client's statement about wanting to die, which indicates suicidal ideation. By asking if the client has thought about harming themselves, the nurse is assessing the client's risk of self-harm and can then take appropriate actions to ensure the client's safety.
Answer A is incorrect as it focuses on the medication issue rather than the client's immediate safety. Answer C is incorrect as it shifts the focus away from the client's suicidal thoughts. Answer D is also incorrect as it doesn't address the immediate risk of self-harm and instead suggests discussing the feelings with the provider without assessing the client's safety first.
Question 5 of 5
A nurse is preparing to provide tracheostomy care for a client. Which of the following actions should the nurse plan to take?
Correct Answer: D
Rationale: The correct answer is D: Secure the tracheostomy in place with a collar that has hook-and-loop fasteners. This is important to prevent accidental dislodgement of the tracheostomy tube. The collar provides stability and security, reducing the risk of complications such as airway obstruction. It also allows for easy adjustment and removal if needed.
A: Wearing clean gloves is important, but it is not directly related to tracheostomy care.
B: Hydrogen peroxide is not recommended for cleansing the skin around the stoma as it can be irritating and drying to the skin.
C: Placing a gauze pad under the flanges is not necessary and may increase the risk of infection or skin breakdown.
Overall, option D is the most appropriate action for tracheostomy care.