ATI RN
ATI RN Fundamentals 2023 I 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: C
Rationale: The correct answer is C: Recheck the client's BP in her other arm for comparison. This is the best course of action to ensure accuracy of the BP reading. By rechecking the BP in the other arm, the nurse can determine if the initial reading was accurate or if there are any significant differences between the arms. This can help identify any potential issues such as arterial blockages or other underlying conditions affecting the BP.
Choice A is incorrect because the width of the BP cuff should be 40% of the upper arm circumference, not 50%.
Choice B is not necessary unless the client is showing signs of distress or discomfort, as it is important to keep the client in the same position for consistent readings.
Choice D is unnecessary unless there are specific reasons to suspect inaccurate readings or if the client's condition changes significantly.
In summary, rechecking the BP in the other arm is the most appropriate action to verify the accuracy of the initial reading and ensure the client's safety.
Question 2 of 5
A nurse is teaching a client about reducing the risk for osteoporosis. Which of the following statements by the client indicates an understanding of possible anaphylaxis?
Correct Answer: D
Rationale: The correct answer is D: A sharp decrease in blood pressure. This indicates an understanding of possible anaphylaxis because anaphylaxis is a severe allergic reaction that can lead to a sudden drop in blood pressure, which can be life-threatening. This symptom is crucial to recognize as it requires immediate medical attention, including the administration of epinephrine.
Choice A, B, and C do not directly relate to anaphylaxis and are more commonly associated with other conditions or reactions. By understanding the potential signs of anaphylaxis, the client can take appropriate actions to seek help promptly.
Question 3 of 5
A nurse enters the room of a client who has a seizure disorder. The client is sitting in a chair and begins to experience a seizure. Which of the following actions should the nurse take first?
Correct Answer: D
Rationale: The correct action is to help the client lie on the floor first. This is crucial to prevent injury during a seizure as it provides a safe environment for the client. By lying on the floor, the client is protected from falling out of the chair, hitting their head, or sustaining other injuries. Moving items in the room away from the client, loosening clothing, and turning the client onto their side are important actions, but they should be done after ensuring the client is safely on the floor. These actions can be taken once the immediate risk of injury is minimized by having the client lie down.
Question 4 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: C
Rationale: The correct answer is C: Recheck the client's BP in her other arm for comparison. This is the best course of action to ensure accuracy of the BP reading. By rechecking the BP in the other arm, the nurse can determine if the initial reading was accurate or if there are any significant differences between the arms. This can help identify any potential issues such as arterial blockages or other underlying conditions affecting the BP.
Choice A is incorrect because the width of the BP cuff should be 40% of the upper arm circumference, not 50%.
Choice B is not necessary unless the client is showing signs of distress or discomfort, as it is important to keep the client in the same position for consistent readings.
Choice D is unnecessary unless there are specific reasons to suspect inaccurate readings or if the client's condition changes significantly.
In summary, rechecking the BP in the other arm is the most appropriate action to verify the accuracy of the initial reading and ensure the client's safety.
Question 5 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: B
Rationale: The correct answer is B: Gloves. The nurse should remove gloves first because they are the most likely to be contaminated, reducing the risk of spreading pathogens. Removing gloves first prevents potential transfer of pathogens to other surfaces or PPE. Eyewear, mask, and gown should be removed in that order after gloves to minimize the risk of exposure. Eyewear protects the eyes, mask protects the nose and mouth, and gown protects clothing from contamination. Removing PPE in the correct order is crucial to prevent the spread of infection.