ATI RN
RN ATI FUNDAMENTALS 2024 EXAM Questions
Extract:
Question 1 of 5
A nurse is initiating a protective environment for a client who has had an allogeneic stem cell transplant. Which of the following precautions should the nurse plan for this client?
Correct Answer: A
Rationale: The correct answer is A: Make sure the client's room has at least six air exchanges per hour. This is important for a client post allogeneic stem cell transplant to reduce the risk of exposure to pathogens. The high air exchange rate helps maintain a clean environment and reduce the transmission of infections.
Choice B is incorrect because wearing a mask outside the room does not address the air quality within the client's room.
Choice C is incorrect as negative-pressure airflow rooms are typically used for clients with airborne infections, not for those post stem cell transplant.
Choice D is incorrect as wearing an N95 respirator is not necessary if the room has adequate air exchanges.
Question 2 of 5
A nurse is teaching a client and his family how to care for the client's tracheostomy at home. Which of the following instructions should the nurse include in the teaching?
Correct Answer: C
Rationale: The correct answer is C: Use sterile technique when performing tracheostomy care at home. This is vital to prevent infections and complications. Sterile technique involves maintaining cleanliness and minimizing the risk of introducing pathogens.
Choices A, B, and D are incorrect. A: Removing the outer cannula carelessly can cause injury or displacement. B: Using tracheostomy covers outdoors is important for filtration but not the primary aspect of care. D: Cleaning mist with hydrogen peroxide can be harmful to the skin and mucous membranes.
Question 3 of 5
A nurse is preparing to administer enoxaparin subcutaneously to a client. Which of the following actions should the nurse take?
Correct Answer: A
Rationale: The correct answer is A: Administer the medication with the needle at a 45° angle. This is the correct action because enoxaparin is a subcutaneous medication that should be injected at a 45° angle to ensure proper absorption and reduce the risk of tissue damage. Administering it at this angle helps to ensure that the medication is effectively delivered into the subcutaneous tissue.
Choice B is incorrect as the administration site is not dependent on the client's dominant arm.
Choice C is incorrect as pulling the skin layer downward is not necessary for subcutaneous injections.
Choice D is incorrect as massaging the injection site after administration can lead to bruising and should be avoided.
Question 4 of 5
A nurse is performing a skin assessment for a client who expresses concern about skin cancer. Which of the following findings should the nurse identify as a potential indication of a skin malignancy?
Correct Answer: C
Rationale: The correct answer is C: A mole with an asymmetrical appearance. The nurse should identify this as a potential indication of skin malignancy because asymmetry is a key characteristic of melanoma, a type of skin cancer. In melanoma, one half of the mole does not match the other half. Other choices are incorrect because: A: A lesion with uniform pigmentation is less likely to be malignant as skin cancer lesions often have irregular borders and uneven colors. B: Petechiae are tiny red or purple spots on the skin caused by bleeding under the skin and are not typically associated with skin cancer. D: The presence of a papule alone is not specific to skin cancer and could be indicative of various skin conditions.
Question 5 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.