ATI RN
RN ATI Comprehensive Assessment Exam Retake 2023 V2 Questions
Extract:
Question 1 of 5
A nurse is performing a neurological examination on a client as part of a complete physical assessment. The nurse should identify that cranial nerve XI is intact when the client performs which of the following actions?
Correct Answer: A
Rationale: The correct answer is A: Shrugs his shoulders. Cranial nerve XI, also known as the spinal accessory nerve, is responsible for controlling the trapezius and sternocleidomastoid muscles, which are involved in shoulder shrugging. When the nurse asks the client to shrug his shoulders against resistance, she is testing the integrity of cranial nerve XI. This action allows the nurse to assess the strength and function of this particular cranial nerve.
Choices B, C, and D are incorrect because they test other cranial nerves. Sticking the tongue out (
B) tests cranial nerve XII (hypoglossal nerve), frowning symmetrically (
C) tests cranial nerve VII (facial nerve), and identifying a sour taste (
D) tests cranial nerve IX (glossopharyngeal nerve). These actions do not involve cranial nerve XI and are therefore not indicators of its intactness.
Question 2 of 5
A nurse is preparing to admit a 6-year-old with varicella to the pediatric unit. Which of the following actions should the nurse take?
Correct Answer: A
Rationale:
Correct
Answer: A - Assign the child to a negative air pressure room.
Rationale:
1. Varicella is highly contagious through airborne transmission.
2. Negative air pressure rooms help prevent the spread of infectious particles.
3. Isolation precautions are essential to protect other patients and healthcare workers.
4. Placing the child in a negative air pressure room minimizes the risk of transmission.
Summary of other choices:
B: Administering aspirin can lead to Reye's syndrome in children with varicella.
C: Droplet precautions are used for diseases like influenza, not varicella.
D: Koplik spots are associated with measles, not varicella.
Question 3 of 5
A charge nurse is teaching a newly licensed nurse about medication administration. Which of the following information should the charge nurse include?
Correct Answer: C
Rationale: The correct answer is C: Inform clients about the action of each medication prior to administration. This is important for promoting patient safety and informed consent. By educating clients about their medications, nurses empower them to be active participants in their own care and help prevent medication errors. Option A is incorrect because preparing medications for multiple clients simultaneously can increase the risk of errors. Option B is incorrect as vomiting after medication administration should be reported to the healthcare provider, not necessarily as an incident report. Option D is incorrect as reading medication labels only once may lead to oversight of important information.
Question 4 of 5
A nurse is planning care for a group of clients and is working with one licensed practical nurse (LPN) and one assistive personnel (AP). Which of the following actions should the nurse take first to manage her time effectively?
Correct Answer: B
Rationale: The correct answer is B: Determine goals of the day. This is the first step to managing time effectively as it helps prioritize tasks and establish a clear direction for care delivery. By setting goals, the nurse can focus on important tasks, delegate appropriately, and allocate time efficiently.
A: Delegating tasks to the AP can come after determining goals to ensure tasks are aligned with priorities.
C: Developing an hourly time frame for tasks can be done once goals are established to create a detailed schedule.
D: Scheduling daily activities is important but should be based on the goals set for the day.
In summary, determining goals of the day is the initial step in time management as it provides a framework for prioritizing tasks and organizing activities efficiently.
Question 5 of 5
A nurse is inserting an indwelling urinary catheter for a male client. Which of the following actions should the nurse take?
Correct Answer: D
Rationale: The correct answer is D: Lift the penis so that it is perpendicular to the client's body. This action helps in straightening the urethra, making it easier to insert the catheter. Lifting the penis perpendicular to the body also reduces the risk of trauma or injury during catheterization.
A, B, and C are incorrect because performing the cleansing procedure two times with a fresh swab, picking up the catheter 13 cm from its tip, and cleansing the tip of the penis in a side-to-side motion are not recommended practices and may increase the risk of contamination or injury.