ATI RN
RN ATI FUNDAMENTALS 2024 EXAM Questions
Extract:
Question 1 of 5
A nurse is evaluating a client's use of a cane. Which of the following actions should the nurse identify as an indication of correct use?
Correct Answer: D
Rationale: The correct answer is D: The client holds the cane on the stronger side of her body. This is correct because when using a cane, it should be held on the stronger side to provide support and stability. Placing the cane on the stronger side helps to offload weight from the weaker side, reducing the risk of falls.
Choice A is incorrect because the top of the cane should ideally be at the level of the greater trochanter, not necessarily parallel to the wrist.
Choice B is vague and does not indicate correct use.
Choice C is incorrect as there is no specific measurement for how far the cane should be moved forward.
Choice E is incorrect as the client should move the weaker limb forward with the cane for support.
Question 2 of 5
A nurse on a medical-surgical unit is caring for a client who has a new prescription for wrist restraints. Which of the following actions should the nurse take?
Correct Answer: A
Rationale: The correct answer is A: Pad the client's wrist before applying the restraints. This is crucial to prevent skin breakdown and ensure the client's comfort. Padding helps distribute pressure and reduces the risk of injury. Option B is incorrect because evaluating circulation every 8 hours is not frequent enough to monitor for potential complications. Option C is incorrect as restraints should be removed every 2 hours, not every 4 hours, to assess the client's status. Option D is incorrect because securing restraint ties to the bed's side rails is unsafe and can lead to injury. It is important to prioritize client safety and comfort when using restraints.
Question 3 of 5
A nurse is assessing four adult clients. Which of the following physical assessment techniques should the nurse use?
Correct Answer: B
Rationale: The correct answer is B: Ensure the bladder or the blood pressure cuff surrounds 50% of the client's arm. This technique is essential for obtaining an accurate blood pressure measurement. Placing the cuff around only 50% of the arm circumference ensures the appropriate pressure on the brachial artery, leading to an accurate reading. If the cuff is too small, the reading will be falsely elevated, and if it's too large, the reading will be falsely low. This step is crucial in preventing errors in blood pressure assessment.
Choice A is incorrect as the FLACC pain rating scale is used for assessing pain in nonverbal patients, not for physical assessment techniques.
Choice C is incorrect as the apical heart rate is obtained by auscultating at the fifth intercostal space, not the third.
Choice D is incorrect because palpating the abdomen before auscultating bowel sounds can lead to altered bowel sounds due to manipulation of the abdomen.
Question 4 of 5
A nurse in a long-term care facility is caring for a client who dies during the nurse's shift. Identify the sequence in which the nurse should perform the following steps. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)
Correct Answer: B, E, C, D, A
Rationale: Correct Order: B, E, C, D, A
Rationale:
1. Obtain the pronouncement of death from the provider (
B) is the first step to officially declare the client deceased.
2. Ask the client's family members if they would like to view the body (E) to involve them in the process and offer closure.
3. Remove tubes and indwelling lines (
C) to ensure the body is prepared for further care.
4. Wash the client's body (
D) as part of maintaining dignity and respect for the deceased.
5. Place a name tag on the body (
A) for identification purposes.
Summary:
- F and G are missing steps and do not contribute to the immediate post-death care.
- Choosing A first may not be appropriate until the body is ready for identification.
- Other steps like notifying authorities or documenting events are not included in the given choices.
Question 5 of 5
A nurse is evaluating a client's use of a cane. Which of the following actions should the nurse identify as an indication of correct use?
Correct Answer: D
Rationale: The correct answer is D: The client holds the cane on the stronger side of her body. This is correct because when using a cane, it should be held on the stronger side to provide support and stability. Placing the cane on the stronger side helps to offload weight from the weaker side, reducing the risk of falls.
Choice A is incorrect because the top of the cane should ideally be at the level of the greater trochanter, not necessarily parallel to the wrist.
Choice B is vague and does not indicate correct use.
Choice C is incorrect as there is no specific measurement for how far the cane should be moved forward.
Choice E is incorrect as the client should move the weaker limb forward with the cane for support.