ATI RN
ATI RN Fundamentals 2023 Exam 5 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 wrist restraints, which of the following actions must the nurse take first?
Correct Answer: D
Rationale: The correct answer is D: Attempt less restrictive alternatives. Before using wrist restraints on a client, the nurse must first try less restrictive measures to ensure the client's safety and well-being. This involves exploring alternative methods to prevent the client from pulling out the IV catheter, such as using soft restraints, diversional activities, or involving family members in supervision. This approach aligns with the principles of patient autonomy and least restrictive intervention, promoting the client's dignity and minimizing the risk of physical and psychological harm. Documenting the indications for using restraints (choice
A), obtaining a prescription (choice
B), and explaining the procedure (choice
C) are important steps but should come after attempting less restrictive measures.
Question 2 of 5
A nurse is completing discharge teaching about ostomy care with a client who has a new stoma. Which of the following instructions should the nurse include in the teaching? (Select all that apply.)
Correct Answer: A,E
Rationale:
Correct Answer: A, E
Rationale:
A: Cutting the opening of the pouch 1/8 inch larger than the stoma prevents irritation and ensures a proper fit.
E: Emptying the pouch when it's one-third full prevents leakage and skin irritation.
Incorrect
Choices:
B: Placing gauze over the stoma can introduce fibers and cause irritation.
C: A purple-blue stoma color may indicate reduced blood flow, not healing.
D: Povidone-iodine can be irritating; mild soap and water are recommended.
Question 3 of 5
A nurse discovers an overlooked prescription for a type and crossmatch of a client who is scheduled for surgery. After notifying the laboratory, which of the following actions should the nurse take?
Correct Answer: C
Rationale: The correct answer is C: Notify the operative team of the omission. This is the correct action because informing the operative team ensures that they are aware of the oversight and can take appropriate steps to address it, such as rescheduling the surgery if necessary. Option A is incorrect as incident reports are usually reserved for significant errors or adverse events. Option B is incorrect because canceling the surgery may not be necessary if the issue can be resolved promptly. Option D is incorrect because simply giving the client another consent form does not address the underlying issue of the missed type and crossmatch.
Question 4 of 5
A nurse is assessing a client whose therapy has included bed rest for several weeks. Which of the following findings should the nurse identify as the priority?
Correct Answer: C
Rationale: The correct answer is C: Left lower extremity tenderness. This finding should be identified as the priority because it could indicate a potential Deep Vein Thrombosis (DVT), a serious complication of prolonged bed rest. DVT can lead to life-threatening conditions like pulmonary embolism. Increased heart rate during physical activity (
A) is expected after a period of inactivity. Loss of appetite (
B) is a common consequence of bed rest but is not as urgent as investigating for DVT. Musculoskeletal weakness (
D) is also expected after prolonged bed rest but does not pose an immediate threat compared to potential DVT.
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: A
Rationale: The correct answer is A. Cranial nerve VII, the facial nerve, controls facial expressions including smiling. Symmetrical smile indicates intact function. B is incorrect as tongue position is assessed by cranial nerve XII. C is related to cranial nerve XI, not VII. D involves cranial nerve II, not VII. E, F, and G are not relevant to cranial nerve VII assessment. In summary, A is correct because it directly relates to the function of cranial nerve VII, while the other choices are unrelated or pertain to different cranial nerves.