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 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.
Question 2 of 5
A nurse is teaching a client who has decreased mobility about passive range-of-motion exercises. Which of the following statements should the nurse make?
Correct Answer: C
Rationale: The correct answer is C: "I will repeat these movements 3 to 5 times." This is the appropriate statement because passive range-of-motion exercises should be repeated multiple times to maintain joint mobility without causing excessive stress on the joints. Option A is incorrect because moving the joints to the point of mild pain can cause discomfort and potential harm. Option B is incorrect as moving the joints quickly may lead to strain or injury. Option D is incorrect because passive range-of-motion exercises are usually performed multiple times throughout the day to prevent joint stiffness.
Question 3 of 5
A nurse is planning care for a client who is immobile. Which of the following actions should the nurse include in the plan of care?
Correct Answer: B
Rationale: The correct answer is B: Use trochanter rolls beside the client's legs. Trochanter rolls help maintain proper alignment of the hips and prevent external rotation of the legs, reducing the risk of pressure ulcers and hip dislocation. Logrolling (choice
A) is not necessary unless specifically indicated for spinal precautions. Placing the client's arms at their side (choice
C) may restrict circulation and lead to discomfort. Crossing the client's ankles (choice
D) could cause pressure ulcers and impair circulation.
Question 4 of 5
A nurse is assessing a client who received an IM antibiotic injection 15 min ago. Which of the following findings should the nurse identify as an indication of a possible anaphylactic reaction to the medication?
Correct Answer: A
Rationale: The correct answer is A: A sharp decrease in blood pressure. An anaphylactic reaction is a severe allergic reaction that can occur rapidly after exposure to an allergen, such as medication. It can lead to a sudden drop in blood pressure due to widespread vasodilation and increased permeability of blood vessels. This can result in shock, a life-threatening condition.
Therefore, the nurse should identify a sharp decrease in blood pressure as a key indicator of an anaphylactic reaction.
Choices B, C, and D are incorrect as they are not typical signs of an anaphylactic reaction. Swelling in the feet, pain at the injection site, and a sudden decrease in heart rate are not specific to anaphylaxis.
Question 5 of 5
A nurse is planning care for a client who has a prescription for extremity restraints to both wrists. Which of the following actions should the nurse include in the plan of care?
Correct Answer: A,C,D
Rationale: The correct actions are A, C, and D.
A: Assessing skin temperature and color before applying restraints helps prevent skin breakdown.
C: Ensuring the bed is in the lowest position reduces fall risk and injury.
D: Padding bony prominences prevents pressure injuries.
B: Attaching restraints to the bed rail can cause harm if the client moves.
E: Allowing three fingers under restraints is too loose and can lead to escape or injury.