ATI RN
ATI RN Fundamentals Updated 2023 Exam Questions
Extract:
Question 1 of 5
A nurse is performing postural drainage with percussion and vibration for a client who has cystic fibrosis. Which of the following actions should the nurse take?
Correct Answer: B
Rationale: The correct answer is B: Cover the area of percussion with a towel. This is important to prevent skin irritation or discomfort during the procedure. The towel acts as a barrier between the client's skin and the nurse's hand, reducing friction and protecting the skin. Performing percussion directly on the skin can cause redness, bruising, or discomfort, so covering the area with a towel is a standard practice to ensure the client's safety and comfort.
Choice A is incorrect because percussion should be performed over specific areas of the chest, not the lower back.
Choice C is incorrect as postural drainage should be scheduled before meals to prevent aspiration.
Choice D is incorrect as clients should exhale slowly and relax during vibration to promote airway clearance.
Question 2 of 5
A nurse is teaching a client how to self-administer daily low-dose heparin injections. Which of the following factors is most likely to increase the client's motivation to learn?
Correct Answer: A
Rationale: The correct answer is A. The client's belief that his needs will be met through education is likely to increase motivation to learn because it aligns with the concept of self-determination theory. This theory posits that individuals are motivated when they perceive that their needs for autonomy, competence, and relatedness are met. In this case, the client believing that his needs will be met through education satisfies his need for competence in managing his health.
Choice B is incorrect because simply being told the need for education may not necessarily increase motivation without the client perceiving a personal benefit.
Choice C is incorrect as seeking family approval is an external motivator and may not necessarily lead to sustained motivation.
Choice D is incorrect as empathy from the nurse, while important, may not directly impact the client's motivation to learn.
Question 3 of 5
A nurse is preparing to administer a controlled substance to a client for pain management. Which of the following actions should the nurse take?
Correct Answer: D
Rationale: The correct answer is D: Verify the count total of the controlled substance after removing the amount needed. This is crucial to ensure accurate documentation and prevent errors in medication administration. By verifying the count total after removing the needed amount, the nurse confirms that the correct dosage has been withdrawn and prevents any discrepancies in the controlled substance inventory.
Option A is incorrect because wasting the unused portion of the controlled substance should be witnessed by another nurse, not just the signature recorded. Option B is incorrect as reporting discrepancies in the count total should be done before administration, not after. Option C is incorrect as wasted portions of controlled substances should be disposed of according to facility policy, not necessarily in a sharps container.
Question 4 of 5
A nurse is preparing to administer IV fluids to a client. The nurse notes sparks when plugging in the IV pump. Which of the following actions should the nurse take first?
Correct Answer: A
Rationale:
Correct Answer: A - Unplug the pump
Rationale: The sparks indicate an electrical issue with the pump, posing a safety hazard. Unplugging the pump immediately is crucial to prevent any potential harm to the client or staff. This action prioritizes safety and addresses the immediate risk.
Incorrect choices:
B: Labeling the pump with a defective equipment sticker does not address the immediate safety concern of the sparks. It is important to prioritize safety first.
C: Obtaining a replacement pump is not necessary until the safety issue is resolved with the current pump.
D: Notifying the biomedical department is important, but the immediate action should be to unplug the pump to prevent any potential harm.
Question 5 of 5
A nurse is caring for a client who is receiving continuous enteral feeding via NG tube. Which of the following is an unexpected finding?
Correct Answer: D
Rationale: The correct answer is D: A gastric residual of 300 mL at the end of the shift. This finding is unexpected because a high residual volume may indicate feeding intolerance or delayed gastric emptying, which can lead to aspiration or other complications. Monitoring gastric residuals helps assess the client's tolerance to enteral feeding.
A: A weight gain of 0.91 kg (2 lb) in 2 days - This could be expected due to fluid retention or intake exceeding output.
B: A blood glucose level of 110 mg/dL - This is within normal range and not unexpected.
C: Diarrhea one time in a 24-hr period - Occasional diarrhea can occur with enteral feeding and is not necessarily unexpected.