ATI RN
ATI RN Fundamentals 2023 Exam 5 Questions
Extract:
Question 1 of 5
A nurse is planning care for a client who has a prescription for knee-length antiembolic stockings. Which of the following actions should the nurse take?
Correct Answer: B
Rationale: Seating the client in a chair for 30 minutes prior to applying the stockings is not necessary. In fact, it is recommended to apply antiembolic stockings while the client is in a supine position to prevent blood from pooling in the legs. This ensures that the stockings fit properly and provide the intended compression to promote venous return. Measuring the length of the client's leg from the heel to the gluteal fold is essential for ensuring the correct fit of knee-length antiembolic stockings. Proper measurement helps in selecting the right size, which is crucial for the stockings to be effective in preventing deep vein thrombosis (DVT) by promoting blood circulation. Incorrectly sized stockings may either be too tight, causing discomfort and impaired circulation, or too loose, failing to provide adequate compression. Instructing the client to point their toes while applying the stockings is not a standard practice. Instead, the nurse should gather the stocking material and gently roll it over the foot and up the leg, ensuring it is evenly distributed and free of wrinkles. This method helps in applying the stockings smoothly and effectively without causing discomfort or improper fit. Rolling the top of the stockings down to just below the knee is incorrect and can lead to a tourniquet effect, which can impede blood flow and increase the risk of DVT. The stockings should be applied smoothly and should extend to their full length without being rolled down to ensure proper compression and effectiveness.
Question 2 of 5
A nurse is administering multiple types of ophthalmic drops to a client. Which of the following actions should the nurse take?
Correct Answer: A
Rationale: Waiting 5 minutes between the administration of each medication is the most appropriate action. This allows each medication to be absorbed properly without being washed away by the subsequent drops. Adequate absorption ensures that each medication can exert its therapeutic effect effectively. Asking the client to close their eyes tightly after instilling each medication is not recommended. This action can force the medication out of the eye, reducing its effectiveness. Instead, clients should be advised to close their eyes gently to allow the medication to spread evenly across the eye surface. Holding the dropper 3 cm (1.2 in) away from the client's eye is too far. The recommended distance is about 1 to 2 cm (0.4 to 0.8 in) to ensure that the drops are accurately placed in the conjunctival sac without touching the eye or eyelashes, which could cause contamination. Massaging the client's eyelids for 20 seconds after instillation is not a standard practice for administering ophthalmic drops. This action could potentially irritate the eye or cause discomfort. Instead, gentle pressure can be applied to the inner corner of the eye (nasolacrimal duct) for a few seconds to prevent the medication from draining into the tear duct.
Question 3 of 5
A nurse is planning an educational program for older adult clients. Which of the following techniques should the nurse use when teaching?
Correct Answer: B
Rationale: Limiting the session to 1 hour is a practical approach when teaching older adults. Research indicates that older adults may have shorter attention spans and may become fatigued more quickly than younger individuals. However, providing a distraction-free environment is more critical for effective learning. Providing an environment with minimal distractions is crucial for effective learning, especially for older adults. Distractions such as noise, poor lighting, and uncomfortable seating can hinder concentration and reduce the effectiveness of the educational program. By creating a calm and focused environment, the nurse can help older adults concentrate better on the material being taught. Presenting the information at a 10th-grade reading level may be too complex for some older adults with varying literacy levels. A lower reading level (e.g., 6th-8th grade) is often recommended for health education to ensure accessibility. Using brightly colored paper can enhance visibility and engagement, especially for those with visual impairments, but it’s less impactful than minimizing distractions for overall comprehension.
Question 4 of 5
A nurse is caring for a client who has dysphagia. When assisting the client during breakfast, which of the following actions by the client indicates the nurse should intervene?
Correct Answer: B
Rationale: Adjusting the head of the bed to 90° is a recommended practice for clients with dysphagia. This position helps facilitate swallowing and reduces the risk of aspiration by using gravity to assist the passage of food and liquids from the mouth to the stomach. Drinking thickened juice with a straw is not recommended for clients with dysphagia. Using a straw can increase the speed and force with which liquids enter the mouth, making it harder to control the swallow and increasing the risk of aspiration. Thickened liquids are designed to move more slowly, giving the client more control over swallowing, but using a straw negates this benefit. Taking frequent breaks while eating is a good practice for clients with dysphagia. It allows them to chew and swallow food thoroughly, reducing the risk of choking and aspiration. This practice also helps prevent fatigue, which can impair swallowing function. Tucking the chin when swallowing, also known as the chin-tuck maneuver, is a common technique used to help clients with dysphagia. This action helps protect the airway by narrowing the space and reducing the risk of aspiration.
Question 5 of 5
A nurse is preparing to lift a box of personal items off the floor in a client's room. Which of the following actions should the nurse take to help prevent injury when lifting the box?
Correct Answer: B
Rationale: Bending at the waist to pick up the box is not recommended as it can put excessive strain on the lower back. Proper lifting techniques involve bending at the knees and hips, not the waist, to use the stronger muscles of the legs and reduce the risk of back injury. This method helps maintain the natural curve of the spine and distributes the load more evenly. When lifting the box, keeping it close to the body is the most appropriate action. This technique reduces the lever arm distance, thereby decreasing the strain on the back muscles and spine. Holding the load close to the body ensures better control and stability, making it easier to lift and carry the box safely. Keeping the feet close together when lifting a box is not advisable. A wide stance, with feet shoulder-width apart, provides better balance and stability. This position allows for a more secure lift and reduces the risk of losing balance or straining muscles during the lifting process. Relaxing the abdominal muscles to prevent straining the back is incorrect. Engaging the core muscles, including the abdominals, provides additional support to the spine and helps maintain proper posture during lifting. Tightening the abdominal muscles can help stabilize the torso and reduce the risk of back injury.