ATI RN
ATI RN Fundamentals 2023 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: 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.
Question 2 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: A
Rationale: The correct answer is A: The client coughs frequently while eating. This is the priority finding as it indicates a risk of aspiration, which can lead to serious complications like pneumonia. The nurse should address this immediately to ensure the client's safety.
Choice B is not as urgent as the client's blood pressure is slightly elevated but not critically high.
Choice C, the client consuming 25% of meals, is concerning but not as immediately life-threatening as aspiration.
Choice D, the client leaning to the left side while sitting, may be related to the left-sided weakness but does not pose an immediate risk to the client's health.
Question 3 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 response acknowledges the client's anxiety and offers support by providing information. It empowers the client by involving them in the discussion and helps alleviate fear of the unknown.
Choice A dismisses the client's feelings and lacks empathy.
Choice B generalizes and may not address the client's specific concerns.
Choice C may come off as confrontational and put the client on the spot.
Question 4 of 5
A nurse is assessing a client who is receiving a blood transfusion. The nurse notes lung crackles, hypoxia, and distended neck veins. Which of the following actions should the nurse take?
Correct Answer: A,B,C
Rationale:
Correct Answer: A, B, C
Rationale:
A: Placing the client in high-Fowler's position helps improve lung expansion and oxygenation.
B: Administering oxygen is crucial to treat hypoxia and improve oxygen levels in the blood.
C: Stopping the transfusion is necessary as the client is showing signs of fluid overload, which can lead to heart failure.
Incorrect choices:
D: Administering a diuretic may worsen the situation by further decreasing fluid volume.
E: Administering epinephrine is not indicated for these symptoms and can worsen the client's condition.
Question 5 of 5
A nurse is performing an eye assessment for a newly admitted client. Which of the following findings should the nurse expect?
Correct Answer: A
Rationale: The correct answer is A: Eyelashes that curl slightly outward. This finding is expected during an eye assessment as it indicates normal eyelash orientation. The eyelashes help protect the eyes from foreign objects.
Choices B, C, and D are incorrect. B is incorrect as the normal blink rate is 15 to 20 times per minute, not 30 to 35. C is incorrect because normal pupil size is 2 to 4 mm in diameter, not 8 to 9 mm. D is incorrect as corneas should be clear, not opaque.