ATI RN
ATI RN Fundamentals Updated 2023 Exam Questions
Extract:
Question 1 of 5
A nurse is planning care for a female client who has an indwelling urinary catheter. Which of the following actions should the nurse include in the plan?
Correct Answer: A
Rationale: The correct answer is A: Keep the drainage bag below the level of the bladder. This is important to prevent backflow of urine into the bladder, reducing the risk of urinary tract infections. Placing the drainage bag below the level of the bladder ensures a continuous flow of urine out of the bladder and into the bag. Option B is incorrect as attaching the drainage bag to the side rails can cause tension on the catheter, leading to displacement or obstruction. Option C is incorrect as the drainage bag should be emptied when it is half-full to prevent backflow or infection. Option D is incorrect as taping the catheter to the lower abdomen can cause tension and discomfort.
Question 2 of 5
A nurse is documenting a dressing change for a client who has a pressure injury. Which of the following entries by the nurse demonstrates correct documentation?
Correct Answer: C
Rationale:
Correct
Answer: C
Rationale:
1. "New dressing applied as prescribed" - This entry documents the action taken by the nurse, ensuring compliance with the care plan.
2. "No drainage on old dressing" - This indicates the status of the wound, showing that there is no abnormal discharge.
3. It provides specific and relevant information related to the dressing change, demonstrating thorough documentation.
Incorrect
Choices:
A: Irrelevant information about premedication with MSO, subq prior to dressing change.
B: Subjective assessment without concrete details or objective findings.
D: Lack of specific details or assessment of the wound's condition.
Overall, choice C provides clear, concise, and relevant information essential for accurate documentation.
Question 3 of 5
A nurse is performing postural drainage with percussion and vibration for a client who has cystic fibrosis. Which of the following actions should the nurse take?
Correct Answer: B
Rationale: The correct answer is B: Cover the area of percussion with a towel. This is important to prevent skin irritation or discomfort during the procedure. The towel acts as a barrier between the client's skin and the nurse's hand, reducing friction and protecting the skin. Performing percussion directly on the skin can cause redness, bruising, or discomfort, so covering the area with a towel is a standard practice to ensure the client's safety and comfort.
Choice A is incorrect because percussion should be performed over specific areas of the chest, not the lower back.
Choice C is incorrect as postural drainage should be scheduled before meals to prevent aspiration.
Choice D is incorrect as clients should exhale slowly and relax during vibration to promote airway clearance.
Question 4 of 5
A nurse is caring for a client who has tuberculosis. Which of the following precautions should the nurse plan to implement when working with the client?
Correct Answer: B
Rationale: The correct answer is B: Airborne precautions. Tuberculosis is spread through the air via droplet nuclei. By implementing airborne precautions, the nurse can prevent the transmission of the disease to others. Airborne precautions include wearing an N95 respirator mask, placing the client in a negative pressure room, and ensuring proper ventilation. Droplet precautions (
Choice
A) are used for diseases spread through respiratory droplets, not airborne particles like tuberculosis. Protective precautions (
Choice
C) are not specific to tuberculosis. Contact precautions (
Choice
D) are used for diseases spread through direct contact with the client or their environment, not through the air like tuberculosis.
Question 5 of 5
A nurse working on a medical-surgical unit is making client assignments for an upcoming shift. Which of the following tasks should the nurse assign to an assistive personnel?
Correct Answer: D
Rationale: The correct answer is D. Assigning the task of assisting with ambulation for a client who has a pulmonary infection to an assistive personnel is appropriate because it is a routine activity that does not require specialized nursing knowledge or skills. Ambulation is a basic care task that can be safely performed by assistive personnel under the supervision of a nurse. It helps promote mobility and prevent complications in clients with pulmonary infections.
Choices A, B, and C involve more complex and skilled nursing interventions that require assessment, critical thinking, and nursing judgment. Inserting a suppository, teaching how to use an incentive spirometer, and irrigating a wound all require specialized nursing knowledge and skills.
Therefore, they should not be assigned to assistive personnel.
In summary, assigning tasks that are routine and do not require nursing judgment to assistive personnel helps optimize nursing resources and promote safe and efficient care delivery.