ATI RN
ATI RN Fundamentals 2023 Questions
Extract:
Question 1 of 5
A nurse is planning care for a client who has acute pain as a result of a pressure injury to the sacrum. Which of the following nonpharmacological interventions should the nurse include in the plan?
Correct Answer: D
Rationale: The correct answer is D: Offer to play music in the client's room. Music therapy has been shown to be an effective nonpharmacological intervention for managing pain. Music can help distract the client from pain, promote relaxation, and reduce anxiety. It can also improve the client's mood and overall well-being. Loosening bed linens (
A) may provide comfort but does not directly address pain management. Massaging the sacrum (
B) can potentially worsen the pressure injury. Bright lights (
C) may increase discomfort for a client in pain.
Therefore, offering music therapy is the most appropriate intervention in this scenario.
Question 2 of 5
A nurse is preparing to set up a sterile field. Which of the following actions should the nurse take?
Correct Answer: A
Rationale: The correct answer is A: Hold bottles of sterile solution with the label in the palm of the hand. This is correct because it ensures that the nurse maintains sterile technique by preventing contamination of the solution. Holding the bottles with the label in the palm of the hand prevents touching the outside of the bottle, which could introduce contaminants.
Choice B is incorrect because pouring liquids into containers outside the sterile field risks contamination.
Choice C is incorrect as the sterile field should be at the level of the nurse's chest to prevent inadvertent contamination.
Choice D is incorrect because opening the outermost flap of the sterile kit toward the body risks contaminating the contents.
Question 3 of 5
A nurse is performing an eye assessment for a newly admitted client. Which of the following findings should the nurse expect?
Correct Answer: A
Rationale: The correct answer is A: Eyelashes that curl slightly outward. This finding is expected during an eye assessment as it indicates normal eyelash orientation. The eyelashes help protect the eyes from foreign objects.
Choices B, C, and D are incorrect. B is incorrect as the normal blink rate is 15 to 20 times per minute, not 30 to 35. C is incorrect because normal pupil size is 2 to 4 mm in diameter, not 8 to 9 mm. D is incorrect as corneas should be clear, not opaque.
Question 4 of 5
A nurse is preparing to provide tracheostomy care for a client. Which of the following actions should the nurse plan to take?
Correct Answer: D
Rationale: The correct answer is D: Secure the tracheostomy in place with a collar that has hook-and-loop fasteners. This is important to prevent accidental dislodgement of the tracheostomy tube, ensuring proper airway patency. Using a collar with hook-and-loop fasteners allows for secure but adjustable placement, accommodating variations in neck size and minimizing the risk of pressure injuries. A: Wearing clean gloves during inner cannula cleaning is essential for infection control but not directly related to securing the tracheostomy. B: Placing a gauze pad under the flanges helps absorb secretions but does not directly address securing the tracheostomy. C: Cleansing the skin with hydrogen peroxide can be too harsh and irritating; a milder solution like saline is preferred.
Question 5 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 safety considerations for an older adult with heart failure taking hydrochlorothiazide. Leaving a light on in the bathroom at night can prevent falls, as older adults are at higher risk due to medication side effects like dizziness from hydrochlorothiazide. Option A is incorrect as regular weight monitoring is crucial for heart failure but should be done more frequently than once weekly. Option B is incorrect as hydrochlorothiazide is typically taken in the morning to avoid frequent urination at night. Option D is incorrect as taking a hot bath before bed can cause dehydration and affect blood pressure, which is not recommended for someone with heart failure.