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 seizure disorder. Which of the following actions should the nurse include in the client's plan of care?
Correct Answer: C
Rationale: Having a padded tongue blade available at the client's bedside is not recommended for seizure management. Inserting any object into a patient's mouth during a seizure can cause injury to the teeth, gums, or jaw. Current guidelines advise against placing anything in the mouth of a person having a seizure. Instead, focus should be on ensuring the patient's safety by turning them on their side to maintain an open airway and prevent aspiration. Keeping the four side rails down when the client is in bed is not advisable for a client with a seizure disorder.
To prevent injury during a seizure, it is important to keep the side rails up and padded. This helps prevent the client from falling out of bed and sustaining injuries. Additionally, the bed should be kept in its lowest position to minimize the risk of injury from falls. Keeping suction equipment available in the client's room is crucial for managing a client with a seizure disorder. During a seizure, there is a risk of aspiration due to excessive salivation or vomiting. Having suction equipment readily available allows the nurse to quickly clear the client's airway, reducing the risk of aspiration and ensuring the client can breathe properly. Having wire cutters available at the client's bedside is not typically necessary for managing a seizure disorder. They are sometimes mentioned in the context of clients with Vagus Nerve Stimulators (VNS), where wire cutters might be used in an emergency to cut the VNS wire. However, this is a rare situation and not a standard precaution for all clients with seizure disorders.
Question 2 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 3 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: C
Rationale: The four-point alternating gait is used when a client can bear weight on both legs. This gait provides maximum stability and is often used for clients with poor balance or coordination. It involves moving one crutch forward, followed by the opposite leg, then the other crutch, and finally the other leg. Since the client can only bear weight on one leg, this gait is not appropriate. The two-point alternating gait is also used when a client can bear weight on both legs. It is faster than the four-point gait and involves moving one crutch and the opposite leg simultaneously, followed by the other crutch and the opposite leg. This gait requires partial weight-bearing on both legs, making it unsuitable for a client who can only bear weight on one leg. The three-point gait is specifically designed for clients who can only bear weight on one leg. In this gait, both crutches are moved forward together, followed by the weight-bearing leg. The non-weight-bearing leg is then swung through. This gait provides the necessary support and stability for clients with one non-weight-bearing leg, making it the most appropriate choice in this scenario. The swing-through gait is used by clients who have good upper body strength and can bear weight on both legs, even if one leg is weaker. This gait involves moving both crutches forward together and then swinging both legs through to the crutches. It is not suitable for a client who can only bear weight on one leg, as it requires some degree of weight-bearing on both legs.
Question 4 of 5
A nurse is ambulating a client who is unsteady. The client begins to fall. Which of the following actions should the nurse take?
Correct Answer: C
Rationale: Moving quickly to a position in front of the client is not recommended. This action could result in both the nurse and the client falling, potentially causing injury to both parties. Remaining upright as the client falls toward them is incorrect. This action does not provide adequate support or control, increasing the risk of injury to the client. Allowing the client to slide down their outstretched leg is the correct action. This technique helps control the fall and minimizes the risk of injury by providing a controlled descent to the floor. Placing their arms around the client to prevent the fall is not advisable. This action can lead to both the nurse and the client falling, which could result in injuries.
Question 5 of 5
A nurse says to their nurse manager, 'I'm the only one on my team who is working hard.' Which of the following responses should the nurse manager make?
Correct Answer: A
Rationale: Why do you feel upset about this?' opens dialogue to explore the nurse’s concerns constructively. Other responses are dismissive, punitive, or assume feelings without fostering discussion.