ATI RN
ATI RN Fundamentals 2023 Questions
Extract:
Question 1 of 5
A nurse is performing an eye assessment for a newly admitted client. Which of the following findings should the nurse expect?
Correct Answer: A
Rationale: The correct answer is A: Eyelashes that curl slightly outward. This finding is expected during an eye assessment as it indicates normal eyelash orientation. The eyelashes help protect the eyes from foreign objects.
Choices B, C, and D are incorrect. B is incorrect as the normal blink rate is 15 to 20 times per minute, not 30 to 35. C is incorrect because normal pupil size is 2 to 4 mm in diameter, not 8 to 9 mm. D is incorrect as corneas should be clear, not opaque.
Question 2 of 5
A nurse is preparing to provide tracheostomy care for a client. Which of the following actions should the nurse plan to take?
Correct Answer: D
Rationale: The correct answer is D: Secure the tracheostomy in place with a collar that has hook-and-loop fasteners. This is important to prevent accidental dislodgement of the tracheostomy tube, ensuring proper airway patency. Using a collar with hook-and-loop fasteners allows for secure but adjustable placement, accommodating variations in neck size and minimizing the risk of pressure injuries. A: Wearing clean gloves during inner cannula cleaning is essential for infection control but not directly related to securing the tracheostomy. B: Placing a gauze pad under the flanges helps absorb secretions but does not directly address securing the tracheostomy. C: Cleansing the skin with hydrogen peroxide can be too harsh and irritating; a milder solution like saline is preferred.
Question 3 of 5
A nurse is providing discharge teaching about safety considerations to an older adult client who lives at home. The client has heart failure and a new prescription for hydrochlorothiazide. Which of the following statements by the client indicates an understanding of the teaching?
Correct Answer: C
Rationale: The correct answer is C: "I will leave a light on in my bathroom at night." This statement indicates an understanding of safety considerations for an older adult with heart failure taking hydrochlorothiazide. Leaving a light on in the bathroom at night can prevent falls, as older adults are at higher risk due to medication side effects like dizziness from hydrochlorothiazide. Option A is incorrect as regular weight monitoring is crucial for heart failure but should be done more frequently than once weekly. Option B is incorrect as hydrochlorothiazide is typically taken in the morning to avoid frequent urination at night. Option D is incorrect as taking a hot bath before bed can cause dehydration and affect blood pressure, which is not recommended for someone with heart failure.
Question 4 of 5
A nurse is collaborating with a risk management team about potential legal issues involving client care. The nurse should identify that which of the following situations is an example of negligence?
Correct Answer: C
Rationale: The correct answer is C. Negligence occurs when a nurse fails to adhere to the standard of care, resulting in harm to the client. Administering medication without identifying the client violates the standard protocol, risking patient safety. Option A relates to lack of informed consent, not negligence. Option B involves restraint, not negligence. Option D pertains to confidentiality breach, not negligence. Thus, option C best exemplifies negligence in client care.
Question 5 of 5
A nurse is performing an eye assessment for a newly admitted client. Which of the following findings should the nurse expect?
Correct Answer: A
Rationale: The correct answer is A: Eyelashes that curl slightly outward. This is an expected finding in an eye assessment as normal eyelashes typically curve slightly outward. Eyelids blinking involuntarily (
B) is a normal physiological response, but the rate mentioned is too high. Pupils (
C) are normally 3 to 4 mm in diameter, not 8 to 9 mm. Corneas with an opaque appearance (
D) suggest a potential issue like corneal edema.