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 nurse should observe the palms of the hands to assess for cyanosis in a client with dark skin because this area is less pigmented and cyanosis is easier to detect. Palms have thinner skin and blood vessels are closer to the surface, making it more likely to show changes in color due to decreased oxygen levels. The sacrum, shoulders, and areas of trauma may not accurately reflect cyanosis in dark-skinned individuals due to the differences in skin pigmentation and thickness. By focusing on the palms, the nurse can accurately assess for cyanosis and provide appropriate care.
Question 2 of 5
A charge nurse is teaching new staff members about factors that increase a client's risk to become violent. Which of the following risk factors should the nurse include as the best predictor of future violence?
Correct Answer: D
Rationale: The correct answer is D: Previous violent behavior. This is the best predictor of future violence because individuals who have a history of violent behavior are more likely to engage in violent acts in the future. This is based on the principle of past behavior being a strong indicator of future behavior.
A: A history of being in prison is not as strong a predictor as previous violent behavior because not all individuals who have been in prison exhibit violent tendencies.
B: Experiencing delusions may increase the risk of violence, but it is not as strong a predictor as previous violent behavior.
C: Male gender is a risk factor for violence, but it is not as specific or reliable as previous violent behavior.
Therefore, the most accurate predictor of future violence is an individual's history of previous violent behavior.
Question 3 of 5
A nurse is providing an in-service about client evacuation during a fire. Which of the following clients should the nurse instruct the staff to evacuate first?
Correct Answer: A
Rationale: The correct answer is A: A client who is ambulatory and receiving oxygen should be evacuated first during a fire. This client has the highest risk due to the combination of mobility impairment and oxygen use, which increases the potential for rapid deterioration in a fire emergency. Oxygen supports combustion, making this client more vulnerable to fire-related injuries.
Choice B: A client with a fracture in balance suspension traction is stable and can wait for evacuation.
Choice C: A bedridden client with a hearing aid can still hear evacuation instructions and wait for assistance.
Choice D: A confused client in a wheelchair may require assistance but is not at immediate risk like the ambulatory client with oxygen.
Question 4 of 5
A nurse is providing discharge teaching to the partner of a client who has a tracheostomy. Which of the following information should the nurse include in the teaching?
Correct Answer: A
Rationale: The correct answer is A: How to operate the portable suction machine. This information is crucial in maintaining a patent airway for the client with a tracheostomy. Suctioning helps to remove secretions and prevent blockages, ensuring proper oxygenation. It is essential for the partner to know how to operate the suction machine safely and effectively.
Choice B is incorrect as securing the tracheostomy tube with ties is important, but it is not the priority in this scenario.
Choice C is incorrect as changing the nondisposable tracheostomy tube daily is not a standard practice and can introduce infection risk.
Choice D is incorrect as changing the tracheostomy dressing should be done using sterile technique, not clean technique, to prevent infection.
Question 5 of 5
A nurse is caring for a client who reports xerostomia following radiation therapy to the mandible. Which of the following is an appropriate action by the nurse?
Correct Answer: B
Rationale: The correct answer is B: Provide humidification of the room air. Xerostomia is dry mouth often caused by radiation therapy, which can lead to discomfort and difficulty swallowing. Humidifying the room air can help alleviate dryness, making it easier for the client to breathe and swallow. Alcohol-based mouthwash (
A) can worsen dryness due to its drying effect. Saltine crackers (
C) can be difficult to swallow with a dry mouth. Esophageal speech (
D) is not relevant to xerostomia.