ATI RN
ATI RN Fundamentals Updated 2023 Exam Questions
Extract:
Question 1 of 5
A nurse is planning care for a client who has a latex allergy and is scheduled for surgery. Which of the following actions is appropriate to include in the client's plan of care?
Correct Answer: B
Rationale: The correct answer is B: Schedule the client as the first surgical procedure of the day. This is appropriate because scheduling the client as the first surgery reduces the risk of exposure to latex, as there will be less latex residue in the operating room. This minimizes the chances of an allergic reaction for the client.
A: Cleansing the stoppers with povidone-iodine does not directly address the latex allergy and does not prevent exposure to latex.
C: Removing the stopcocks from IV tubing may reduce latex exposure, but scheduling the client as the first procedure is more effective.
D: Ensuring that gloves in the surgical suite are powdered can actually increase the risk of allergic reactions as the powder can contain latex particles.
Therefore, choosing option B is the most appropriate and effective action to include in the client's plan of care.
Question 2 of 5
A nurse is caring for a client who has wrist restraints after an episode of violent behavior. Which of the following actions should the nurse take?
Correct Answer: B
Rationale: The correct answer is B. Removing one restraint at a time allows for gradual release of restraint pressure, preventing sudden movement that could result in injury. Tying restraints to the side rail (
A) increases risk of injury. Securing restraints with a square knot (
C) may be difficult to untie quickly in an emergency. Removing restraints every 3 hours (
D) does not address the immediate need for safety.
Question 3 of 5
A nurse working on a medical-surgical unit is making client assignments for an upcoming shift. Which of the following tasks should the nurse assign to an assistive personnel?
Correct Answer: D
Rationale: The correct answer is D. Assigning the task of assisting with ambulation for a client who has a pulmonary infection to an assistive personnel is appropriate because it is a routine activity that does not require specialized nursing knowledge or skills. Ambulation is a basic care task that can be safely performed by assistive personnel under the supervision of a nurse. It helps promote mobility and prevent complications in clients with pulmonary infections.
Choices A, B, and C involve more complex and skilled nursing interventions that require assessment, critical thinking, and nursing judgment. Inserting a suppository, teaching how to use an incentive spirometer, and irrigating a wound all require specialized nursing knowledge and skills.
Therefore, they should not be assigned to assistive personnel.
In summary, assigning tasks that are routine and do not require nursing judgment to assistive personnel helps optimize nursing resources and promote safe and efficient care delivery.
Question 4 of 5
A nurse is caring for a client who is 2 days postoperative following bowel resection and reports sudden, severe abdominal pain. Which of the following actions should the nurse take first?
Correct Answer: D
Rationale: The correct answer is D: Expose the client's abdomen to look for changes in appearance. This action should be taken first because sudden, severe abdominal pain postoperatively can indicate a serious complication like internal bleeding or bowel perforation. By exposing the abdomen, the nurse can visually assess for signs of distention, discoloration, or any other abnormality that may indicate a surgical complication. This visual assessment can provide crucial information to guide further interventions.
Choices A, B, and C involve assessment techniques that may be important in evaluating the client's condition, but they should be secondary to visually inspecting the abdomen in this urgent situation.
Choice A focuses on bowel sounds, which may not be reliable in a postoperative client experiencing sudden severe pain.
Choice B involves palpation, which could potentially exacerbate any existing complications.
Choice C refers to assessing areas of resonance, which is less urgent compared to visually inspecting for immediate changes in the abdomen.
In summary, visually inspecting the client's
Question 5 of 5
A nurse is preparing to perform a physical assessment of a client's abdomen. Identify the sequence in which the nurse should perform the following steps.
Correct Answer: A,B,C,E,D
Rationale: Action to Take: A, B; Potential Condition: C; Parameter to Monitor: D, E.
The correct sequence for performing a physical assessment of a client's abdomen involves the following steps:
1. Provide adequate lighting to inspect the abdomen (Action
A) to ensure clear visibility.
2. Listen to the abdominal arteries using the bell of a stethoscope (Action
B) to assess vascular sounds.
3. Percuss all four quadrants of the abdomen (Potential Condition
C) to measure sound quality and identify any abnormalities.
4. Check for areas of tenderness by pressing fingers 1.3 cm (0.5 in) into the abdomen (Parameter to Monitor E) to assess for pain or discomfort.
5. Locate liver and spleen borders by pressing hands 2.5 to 7.5 cm (1 to 3 in) into the abdomen (Parameter to Monitor
D) to assess organ size and position.
This sequence ensures a systematic and comprehensive assessment of the abdomen,