ATI RN
ATI RN Fundamentals 2023 II Questions
Extract:
Question 1 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: D
Rationale: The correct answer is D: Recheck the client's BP in her other arm for comparison. By rechecking the BP in the other arm, the nurse can determine if the initial reading was accurate or if there is a significant difference between the two arms. Discrepancies in readings between arms could indicate issues like arterial blockages or other vascular problems. This step is crucial in ensuring an accurate and reliable blood pressure measurement.
Choice A is incorrect because waiting 30 minutes may not address the potential issue of a discrepancy between the arms.
Choice B is incorrect as the width of the BP cuff should be appropriate for the arm size, not necessarily 50% of upper arm circumference.
Choice C is unnecessary as repositioning the client may not address the potential discrepancy in BP readings.
Question 2 of 5
A nurse is caring for a client who is anxious about being admitted to a health care facility for the first time. Which of the following statements should the nurse make?
Correct Answer: D
Rationale: The correct answer is D: "We can discuss what you can expect during your stay." This statement acknowledges the client's feelings of anxiety and offers support by providing information to help alleviate their fears. It promotes open communication, builds trust, and empowers the client by involving them in the care process. It also addresses the client's need for information and helps them feel more prepared for their stay.
Choice A is incorrect as it focuses on the client's fear rather than providing reassurance or support.
Choice B is incorrect as it generalizes the client's feelings without addressing their specific concerns.
Choice C is incorrect as it dismisses the client's anxiety without offering any information or support.
Question 3 of 5
A nurse in an emergency department is caring for a client who is unconscious and requires surgery. There is no one available to give consent for the treatment. Which of the following actions should the nurse take?
Correct Answer: A
Rationale: The correct answer is A: Prepare the client for surgery. In emergency situations where a client is unconscious and requires immediate surgery to prevent harm or save their life, healthcare providers are ethically obligated to act in the client's best interest. This principle, known as beneficence, allows healthcare professionals to provide necessary care in emergency situations without prior consent. By preparing the client for surgery, the nurse ensures the client receives timely and potentially life-saving treatment. Obtaining consent from the surgeon (
B) is not appropriate as the surgeon cannot provide consent on behalf of the client. Contacting the facility's ethics committee (
C) may cause unnecessary delays in providing urgent care. Keeping the client stable until a family member arrives (
D) may jeopardize the client's health and violates the principle of beneficence.
Question 4 of 5
A nurse is assessing a client who has left-sided weakness following a stroke. Which of the following findings is the nurse's priority?
Correct Answer: C
Rationale: The correct answer is C: The client coughs frequently while eating. This is the priority finding because it indicates a risk for aspiration, a potentially life-threatening complication post-stroke. Aspiration occurs when food or liquids enter the airway instead of the esophagus, leading to choking or pneumonia. The nurse should address this immediately by modifying the client's diet consistency or positioning during meals to prevent aspiration.
The other choices are not the priority because:
A: The client's blood pressure being 142/94 mm Hg is elevated but not immediately life-threatening in this context.
B: Consuming only 25% of meals may indicate dysphagia or decreased appetite, which are important but not as urgent as the risk of aspiration.
D: Leaning to the left side while sitting is likely due to the left-sided weakness and can be addressed with positioning adjustments but is not as urgent as preventing aspiration.
Question 5 of 5
A nurse is planning care for a client who is scheduled for an intravenous pyelogram. Which of the following actions is appropriate for the nurse to include?
Correct Answer: C
Rationale: The correct answer is C: Assist the client with a bowel cleansing. Prior to an intravenous pyelogram, it is important to ensure the client has a clear bowel to improve visualization of the urinary tract. This is typically achieved through bowel cleansing to prevent any fecal material from obstructing the view of the kidneys and bladder during the procedure.
Incorrect choices:
A: Ensuring the client is free of metal objects is important for MRI scans, not intravenous pyelograms.
B: Monitoring for pain in the suprapubic region is not a standard preparation for an intravenous pyelogram.
D: Administering oral contrast is not typically required for an intravenous pyelogram, as the contrast material is injected intravenously for this procedure.