ATI RN
ATI Fundamental Proctored Exam Simulated Exam Questions With Detailed Verified Answer Questions
Extract:
Question 1 of 5
A nurse is considering placing wrist restraints on a client who has cognitive deficits and has pulled out their IV catheter. Before using restraints, which of the following actions must the nurse take first?
Correct Answer: C
Rationale:
Correct Answer: C - Attempt less restrictive alternatives.
Rationale: Before resorting to restraints, the nurse must try less restrictive measures to ensure the client's safety. This includes using soft restraints, diversion techniques, or involving family members. This approach aligns with the principles of patient autonomy and least restrictive interventions. It also helps prevent potential harm or discomfort that may be caused by the use of restraints.
Summary of other choices:
A: Obtaining a prescription is important, but exploring alternatives should come first.
B: While communication is key, trying other options for safety takes precedence.
D: Documentation is necessary but should follow the exploration of less restrictive methods.
Overall, attempting less restrictive alternatives is crucial for ethical and safe care.
Question 2 of 5
A nurse is providing discharge teaching to the partner of a client who has a linear incision site following an open cholecystectomy. Which of the following wound care instructions should the nurse include?
Correct Answer: C
Rationale: The correct answer is C: Use sterile gloves when removing the old dressing. This is important to prevent introducing infection to the wound. Sterile gloves help maintain aseptic technique and reduce the risk of contamination. Changing the dressing four times per day (choice
A) can lead to excessive handling and potential contamination. Applying tincture of benzoin prior to removing the dressing (choice
B) is unnecessary and may irritate the skin. Cleaning from the incision to the surrounding skin (choice
D) risks introducing pathogens into the incision site.
Question 3 of 5
A nurse is assessing a client's cranial nerve VII. Which of the following responses should the nurse expect?
Correct Answer: D
Rationale: The correct answer is D: The client has a symmetrical smile. Cranial nerve VII, the facial nerve, controls facial expressions including smiling. Assessing for a symmetrical smile helps determine if the nerve is functioning properly. A is incorrect as it relates to cranial nerve XI. B is incorrect as it relates to cranial nerve XII. C is incorrect as it relates to cranial nerve II.
Question 4 of 5
A nurse is planning to use nonpharmacological pain relief methods for a client who reports continued mild back pain after receiving analgesia 1 hr ago. Which of the following actions should the nurse include in the plan?
Correct Answer: B
Rationale: The correct answer is B: Instruct the client to take deep, rhythmic breaths. Deep breathing can help the client relax, distract from pain, and improve oxygenation, reducing perception of pain. This method is non-invasive and can be easily implemented by the client.
Choice A may provide temporary relief but is not recommended for prolonged periods as it can lead to skin damage.
Choice C may exacerbate the pain as ice is not indicated for mild back pain.
Choice D may help create a calming environment but does not directly address the pain.
Question 5 of 5
A nurse is administering multiple types of ophthalmic drugs to a client. Which of the following actions should the nurse take?
Correct Answer: D
Rationale: The correct answer is D: Wait 5 min between the administration of each medication. This is important to prevent dilution of the medication and ensure proper absorption in the eye. Waiting between administrations allows each medication to have its full effect before the next one is introduced. Holding the dropper 3 cm away from the eye (
A) is incorrect as it may cause inaccurate dosing. Asking the client to close their eyes tightly after instillation (
B) can prevent proper absorption. Massaging the client's eyelids (
C) can lead to contamination or injury. Waiting 5 min between medications is the best practice to ensure each drug is absorbed effectively.