ATI RN
ATI RN Fundamentals Exam 6 Questions
Extract:
Question 1 of 5
A nurse is planning care for an older adult client who has urinary incontinence. Which of the following interventions should the nurse include in the client's plan of care?
Correct Answer: A
Rationale: Applying a moisture barrier helps protect the skin from irritation and breakdown due to prolonged exposure to moisture. Cleansing the skin with antibacterial soap and hot water may be too harsh and can contribute to skin irritation; gentle cleaning with a mild cleanser is preferable.
Toileting the client every 4 hours may not be frequent enough to prevent skin breakdown; a more frequent toileting schedule should be implemented. Reducing the client's daily fluid intake is not a recommended intervention for urinary incontinence as it may lead to dehydration and other health issues.
Question 2 of 5
A nurse is teaching a client how to self-administer daily low-dose heparin injections. Which of the following factors is most likely to increase the client's motivation to learn?
Correct Answer: A
Rationale: The client's belief that his needs will be met through education reflects intrinsic motivation which is likely to enhance the client's commitment to learning and self-care. Seeking family approval may be a motivator but it is an external factor and intrinsic motivation is generally more effective for sustained behavior change. While the nurse explaining the need for education is important the client's personal belief and understanding of the value of education are key for motivation. The nurse's empathy is essential for building rapport but the client's belief in the benefits of education is more directly related to motivation.
Question 3 of 5
A nurse is evaluating a client's use of crutches. Which of the following observations indicates safe use of this equipment?
Correct Answer: D
Rationale: Placing one crutch on each side when assuming a sitting position is not the correct technique. The client should use both crutches on one side to provide support when sitting or rising. Placing weight on the axillae when walking can cause nerve damage and is an incorrect crutch-walking technique. The client should bear weight on the hands and arms not the axillae. Moving the unaffected leg onto a step first when descending stairs is a correct and safe technique for using crutches on stairs. Having slightly flexed elbows when ambulating with crutches is a proper technique for maintaining balance and support while walking.
Question 4 of 5
A 5-year-old client is refusing to let the nurse take his blood pressure. To promote cooperation the nurse should:
Correct Answer: C
Rationale: Telling the child that it will not hurt may not be effective as children may still have anxiety or fear related to the unknown. Forcing a child or having the parent hold tightly may increase anxiety and make the child more resistant to the procedure. Allowing the child to operate the equipment can give the child a sense of control and involvement increasing cooperation. Deferring the procedure until the next visit may not be practical or necessary if alternative strategies can be employed to promote cooperation.
Question 5 of 5
A nurse on a medical-surgical unit is preparing to administer medication to a client for the first time. Which of the following client identifiers are appropriate for the nurse to use before administering the medication? (Select all that apply.)
Correct Answer: A,C,D
Rationale: Date of birth is a commonly used identifier to confirm the client's identity. Diagnosis is not an appropriate identifier for confirming a client's identity. Identification number is a unique identifier assigned to each client helping ensure accurate identification. Name is a fundamental identifier and should be used in combination with other identifiers to verify the client's identity. Room number is not an appropriate identifier for confirming a client's identity.