ATI RN
ATI RN Fundamentals 2023 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?
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.
Question 2 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: C
Rationale: The correct answer is C: "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 are at risk for falls due to potential nocturia (frequent need to urinate at night) caused by the diuretic effect of hydrochlorothiazide. Leaving a light on in the bathroom at night can help prevent falls.
Choice A is incorrect because weighing once weekly does not address the immediate safety concern related to falls.
Choice B is unrelated to safety considerations.
Choice D is incorrect as taking a hot bath before bed can potentially increase the risk of falls due to dizziness.
Question 3 of 5
A nurse is prioritizing care for a client. Which of the following procedures should the nurse perform first?
Correct Answer: D
Rationale: The correct answer is D: Endotracheal suctioning. This procedure should be prioritized as it helps maintain a patent airway, which is crucial for the client's oxygenation and ventilation. Without a clear airway, the client may experience respiratory distress or compromise. Urinary catheter care (
A) is important but not immediately life-threatening. Enteral feeding (
B) and wound irrigation (
C) can be delayed as they do not directly impact the client's airway. Endotracheal suctioning takes precedence over these procedures.
Question 4 of 5
A nurse is caring for a client who requires airborne precautions. The nurse is preparing to leave the client's room following a dressing change. Which of the following pieces of personal protective equipment should the nurse remove first?
Correct Answer: C
Rationale: The correct answer is C: Gloves. The nurse should remove gloves first after a dressing change to prevent contamination of other surfaces. Gloves are the primary barrier protecting the nurse from direct contact with bodily fluids. Removing gloves first helps minimize the risk of spreading pathogens. Removing eyewear, mask, or gown first could potentially expose the nurse to airborne pathogens or splash contamination. Removing the mask or gown first could also lead to contamination of the nurse's face or clothing. Removing gloves first ensures proper infection control practices are followed.
Question 5 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 suitable for a client who can only bear weight on one leg. In a three-point gait, the client advances both crutches and the affected leg together followed by the unaffected leg. This maintains stability and minimizes weight-bearing on the affected leg. The other choices are incorrect because:
A: Two-point alternating gait requires partial weight-bearing on both legs.
B: Four-point alternating gait involves slow and stable movement, not ideal for a client with weight-bearing restrictions on one leg.
C: Swing-through gait involves both legs swinging through, which is not suitable for a client with weight-bearing restrictions on one leg.