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 using restraints, the nurse must first try less restrictive measures to ensure the safety and well-being of the client. This includes interventions such as redirecting the client's behavior, providing distractions, or addressing the underlying cause of the behavior. By attempting less restrictive alternatives, the nurse can promote the client's autonomy and prevent the potential negative effects of using restraints.
Summary:
A: Obtaining a prescription for restraints is important, but it should not be the first step.
B: Explaining the procedure to the client and their family is important but does not address the immediate need for less restrictive alternatives.
D: Documenting the indications for using wrist restraints is necessary but does not address the need to explore other options first.
Question 2 of 5
A staff nurse is teaching a newly hired nurse how to complete an informed consent document for a client. The staff nurse should include that the nurse's signature on the form confirms which of the following requirements? (Select all that apply.)
Correct Answer: B,D,E
Rationale: The correct answers are B, D, and E. B is essential as the client must have legal authority to give informed consent. D is crucial as the client's signature in the nurse's presence ensures authenticity. E is important to confirm that the client was not coerced.
Choice A is incorrect as language proficiency does not determine consent validity.
Choice C is incorrect as having a mental health condition does not automatically invalidate consent.
Question 3 of 5
A home health nurse is performing a fall risk assessment for an older adult client. Which of the following findings should the nurse identify as a potential fall risk in the home?
Correct Answer: A
Rationale: The correct answer is A because taking antihypertensive medication can lead to orthostatic hypotension, increasing fall risk.
Choice B is incorrect as securing electrical wires actually reduces tripping hazards.
Choice C is incorrect as rubber-sole shoes provide better traction.
Choice D is incorrect as 20/40 visual acuity alone may not directly contribute to fall risk.
Question 4 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 or interaction between the different ophthalmic medications. Administering multiple medications too close together can reduce the effectiveness of each medication. Holding the dropper at a specific distance (
A) is not as critical as allowing time between administrations. Asking the client to close their eyes tightly (
B) or massaging the eyelids (
C) after instillation can disrupt the medication and should be avoided. Waiting for 5 minutes allows each medication to be properly absorbed before the next one is administered, ensuring optimal therapeutic effects.
Question 5 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 expression including smiling. When assessing this nerve, the nurse would expect the client to have a symmetrical smile indicating intact function. This is because cranial nerve VII innervates the muscles of facial expression.
Choices A, B, and C are incorrect as they are not specific to cranial nerve VII assessment. The turning of the head against resistance (
A) would be more related to cranial nerve XI, the accessory nerve. The tongue position (
B) is controlled by cranial nerve XII, the hypoglossal nerve. Pupillary constriction in response to light (
C) is regulated by cranial nerve II, the optic nerve.