ATI RN
ATI Fundamentals 2023 Retake Questions
Extract:
Question 1 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? (Select all that apply.)
Correct Answer: B,D,E
Rationale: The correct answer includes choices B, D, and E. Padding bony prominences before applying restraints prevents skin breakdown and discomfort. Ensuring the bed is in the lowest position prevents falls and injury. Assessing skin temperature and color before applying restraints ensures proper circulation and skin integrity.
Choice A is incorrect as attaching restraints to the bed rail can cause harm or restrict movement.
Choice C is incorrect as restraints should allow room for only two fingers to slide under, not three.
Question 2 of 5
A nurse is assessing a client who is receiving a blood transfusion. The nurse notes lung crackles, hypoxia, and distended neck veins. Which of the following actions should the nurse take? (Select all that apply.)
Correct Answer: A,B,D,E
Rationale:
Correct
Answer: A, B, D, E
Rationale:
A: Obtain a prescription for a diuretic - Lung crackles and distended neck veins indicate fluid overload, so a diuretic can help to reduce fluid volume.
B: Administer oxygen to the client - Hypoxia indicates inadequate oxygenation, so administering oxygen is crucial to improve oxygen levels.
D: Stop the transfusion - These signs suggest a transfusion reaction, so stopping the transfusion is essential to prevent further harm.
E: Place the client in high-Fowler's position - Elevating the client's head can help improve breathing and oxygenation by reducing pressure on the lungs.
Summary of Incorrect
Choices:
C: Administer epinephrine to the client - Epinephrine is not indicated for fluid overload or transfusion reaction symptoms.
F: No information provided.
G: No information provided.
Question 3 of 5
A nurse is preparing to reposition a client who has a lower back injury. Which of the following actions should the nurse take?
Correct Answer: B
Rationale: The correct answer is B: Roll the client as one unit in a smooth, continuous motion. This is the safest method to reposition a client with a lower back injury because it minimizes strain on the back and reduces the risk of injury. Rolling the client as one unit maintains the alignment of the spine and prevents unnecessary twisting or bending. Flexing the client's knees (choice
A) may be uncomfortable or cause further strain on the lower back. Placing the client on the side of the bed nearest the direction they will be turned (choice
C) is not as crucial as rolling the client as one unit. Placing the client's arms at their sides (choice
D) does not directly address the proper repositioning technique for a client with a lower back injury.
Question 4 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: B
Rationale: The correct answer is B: "I will leave a light on in my bathroom at night." This statement indicates an understanding of the teaching because older adults with heart failure who take hydrochlorothiazide are at risk for nocturia (nighttime urination) due to the medication's diuretic effect. Leaving a light on in the bathroom at night can prevent falls and accidents during nighttime bathroom visits.
Choice A: "I will take a hot bath before going to bed." - Incorrect, as hot baths before bed can potentially worsen heart failure symptoms by increasing heart rate and blood pressure.
Choice C: "I will weigh myself once weekly." - Incorrect, as monitoring weight daily is crucial for individuals with heart failure and taking diuretics to manage fluid retention.
Choice D: "I will take my new medication in the evening." - Partially correct, but the priority in this scenario is safety considerations, not medication timing.
Question 5 of 5
A nurse is admitting a client who is at risk for falls to a medical-surgical unit. Which of the following actions should the nurse take?
Correct Answer: A
Rationale: The correct answer is A: Provide the client with a night light. This is important for fall prevention as it helps the client see clearly at night, reducing the risk of tripping or falling in the dark. Night lights can improve visibility and safety without disrupting sleep.
Choice B could potentially restrict the client's movement and increase the risk of entrapment.
Choice C does not directly address fall prevention.
Choice D focuses on room temperature, which is not directly related to fall risk.