ATI RN
RN-ATI-Fundamentals-of-Nursing-2023-2024 Questions
Extract:
Question 1 of 5
A nurse is performing a skin assessment on a client who has dark skin. Which of the following locations on the client's body should the nurse observe to assess for cyanosis?
Correct Answer: B
Rationale: The correct answer is B: Palms of the hands. In dark-skinned individuals, cyanosis, a bluish discoloration of the skin due to decreased oxygen levels, can be difficult to detect. The palms of the hands are one of the best areas to assess for cyanosis in dark skin because the skin is thinner, allowing for better visualization of color changes. Other locations like the sacrum, shoulders, and areas of trauma may not provide an accurate assessment for cyanosis due to differences in skin thickness and pigmentation.
Therefore, observing the palms of the hands allows for a more reliable assessment of cyanosis in clients with dark skin.
Question 2 of 5
A nurse is responding to a call light and finds a client lying on the bathroom floor. Which of the following actions should the nurse take first?
Correct Answer: A
Rationale: The correct action is to check the client for injuries first. This is crucial to assess the immediate physical condition of the client and determine the severity of any potential harm. This step ensures timely intervention and appropriate care. Moving hazardous objects (
B) is important, but not the first priority. Notifying the provider (
C) can be done after ensuring the client's safety. Asking the client about how she felt (
D) can wait until the immediate safety concerns are addressed.
Question 3 of 5
A nurse is reinforcing teaching with a client who has hypertension and a prescription to measure her blood pressure daily. Which of the following client statements indicates an understanding of the teaching?
Correct Answer: C
Rationale:
Correct Answer: C - "I should remove constrictive clothing prior to measuring my blood pressure."
Rationale: Removing constrictive clothing ensures accurate blood pressure readings by preventing constriction that may falsely elevate the readings. This statement demonstrates an understanding of the importance of proper preparation for accurate measurements.
Choice A is incorrect because waiting 15 minutes after drinking coffee is not necessary for accurate blood pressure measurement.
Choice B is incorrect because measuring blood pressure with the arm elevated above the heart can lead to inaccurate readings.
Choice D is incorrect because measuring blood pressure immediately after eating can also lead to inaccurate results due to the body's postprandial response.
The correct choice, C, emphasizes the importance of removing constrictive clothing, which is crucial for obtaining accurate blood pressure readings.
Question 4 of 5
A nurse is assessing an older adult client's risk for falls. Which of the following assessments should the nurse use to identify the client's safety needs? (Select all that apply.)
Correct Answer: B,C,D,E
Rationale: The correct assessments for identifying an older adult client's safety needs are B, C, D, and E. Pupil clarity is important to assess for any visual impairments that may affect balance and mobility. The appearance of bulbar conjunctivae can indicate any eye conditions that might increase fall risk. Evaluating visual fields can detect peripheral vision issues that can impact navigation and safety. Lastly, assessing visual acuity is crucial to determine the client's ability to see clearly and avoid obstacles.
Choices A and F are irrelevant to assessing fall risk in older adults.
Choice G is not provided.
Question 5 of 5
A nurse is assessing a client who has preeclampsia and is receiving magnesium sulfate via continuous IV infusion. For which of the following therapeutic effects should the nurse monitor the client?
Correct Answer: A
Rationale: The correct answer is A: Deep tendon reflexes 2+. In clients receiving magnesium sulfate for preeclampsia, monitoring deep tendon reflexes is crucial as magnesium sulfate can lead to muscle weakness and decreased reflexes, indicating potential toxicity. Monitoring for 2+ reflexes ensures the client is within the therapeutic range. Pulse rate (
B) and urine output (
C) are important to monitor but are not specific therapeutic effects of magnesium sulfate. Proteinuria (
D) is a sign of preeclampsia and not a therapeutic effect of the medication.