ATI RN
ATI RN Fundamentals 2023 II Questions
Extract:
Question 1 of 5
A nurse is planning care for a client who has a new prescription for parenteral nutrition (PN) in 20% dextrose and fat emulsions. Which of the following is an appropriate action to include in the plan of care?
Correct Answer: D
Rationale: The correct answer is D: Prepare the client for a central venous line. Parenteral nutrition with high dextrose concentrations and fat emulsions can be highly osmotic and irritating to peripheral veins, leading to vein damage and thrombophlebitis.
Therefore, a central venous line is necessary to prevent these complications and ensure safe administration of PN. Administering the PN and fat emulsion separately (
A) would not address the need for a central venous line. Changing the PN infusion bag every 48 hours (
B) is not directly related to the need for a central venous line. Obtaining a random blood glucose daily (
C) is important for monitoring but does not address the need for a central venous line to administer PN.
Question 2 of 5
A home health nurse is caring for a client who has a chronic illness and recently moved in with their adult child. Which of the following statements by the client should indicate to the nurse that the client has adapted to their new situational role?
Correct Answer: D
Rationale: The correct answer is D. This statement indicates that the client has adapted to their new situational role because it shows acceptance and appreciation of the assistance provided by their adult child. By stating, "It's nice having other people cook for me," the client acknowledges and values the support and care being offered, demonstrating a positive adjustment to their changed living situation.
A: This statement suggests a desire for independence, which may indicate the client is not fully adapted to relying on their adult child.
B: This statement indicates confusion and uncertainty, signaling a lack of adjustment to their new living arrangement.
C: This statement reflects a reluctance to ask for help, which may hinder the client's ability to adapt and receive necessary support.
Question 3 of 5
A nurse is teaching a client how to self-administer heparin. Which of the following instructions should the nurse include in the teaching?
Correct Answer: C
Rationale:
Correct Answer: C - Expel air bubble before injecting medication.
Rationale:
1. Air bubbles can cause harm if injected into the bloodstream.
2. Expelling air ensures accurate dosage delivery.
3. Prevents air embolism, a potentially fatal complication.
4. Promotes safe and effective administration of heparin.
Summary:
A: Using an 18-gauge needle is too large and may cause discomfort.
B: Massaging the site can lead to bruising or discomfort.
D: Injecting 2 inches away from umbilicus is not a standard practice for heparin administration.
Question 4 of 5
A nurse is teaching a client who can only bear weight on one leg how to ambulate using crutches. Which of the following crutch gaits should the nurse plan to instruct the client to use?
Correct Answer: D
Rationale: The correct answer is D: Three-point gait. This gait is appropriate for a client who can only bear weight on one leg. In a three-point gait, the client moves both crutches and the affected leg forward together, then advances the unaffected leg. This gait provides maximum support and stability for the client while keeping weight off the affected leg. Other options are incorrect: A: Four-point gait involves alternating movement of crutches and feet, not suitable for one-legged weight-bearing. B: Two-point gait requires partial weight-bearing on both legs, not appropriate for this client. C: Swing-through gait involves swinging both legs through, unsuitable for one-legged weight-bearing.
Question 5 of 5
A charge nurse is observing a staff nurse performing a wound irrigation for a client who has a pressure injury. Which of the following actions by the staff nurse indicates an understanding of the procedure?
Correct Answer: D
Rationale: The correct answer is D because administering an analgesic medication 5 minutes before starting wound irrigation indicates an understanding of the procedure. Pain management is crucial to ensure client comfort during wound care.
Choice A is incorrect as a syringe with a catheter is not typically used for wound irrigation.
Choice B is incorrect as refrigerating the solution is unnecessary and may cause discomfort to the client.
Choice C is incorrect as using one pair of gloves for both dressing removal and irrigation increases the risk of cross-contamination.