ATI RN
ATI Fundamentals 2023 Retake Questions
Extract:
Question 1 of 5
A nurse is planning to change a client's tracheostomy ties. Which of the following actions should the nurse take?
Correct Answer: B
Rationale: The correct answer is B: Cut the old ties after the new ties are secured. This is the correct action because it ensures that the tracheostomy tube remains secure during the tie change process. By securing the new ties first before cutting the old ties, the nurse maintains the stability of the tracheostomy tube to prevent accidental dislodgment.
Choice A is incorrect because allowing space for three fingers under the ties may not provide adequate security.
Choice C is incorrect as using a quick-release knot may lead to accidental loosening of the ties.
Choice D is incorrect as extending the client's neck may cause discomfort or compromise the airway. It is essential to prioritize the safety and security of the tracheostomy tube during tie changes.
Question 2 of 5
A nurse is caring for a client who has a colostomy. Which of the following actions should the nurse take?
Correct Answer: B
Rationale: The correct answer is B: Ensure the pouch is 0.32 cm (1/8 in) larger than the stoma. This is crucial to prevent irritation and pressure on the stoma, allowing proper flow of stool into the pouch.
Choice A is incorrect as applying the pouch while the skin barrier is damp can cause skin breakdown.
Choice C is incorrect as rubbing the peristomal skin dry can cause irritation.
Choice D is incorrect as changing the pouch every 24 hours is unnecessary unless leakage or irritation occurs.
Question 3 of 5
A nurse is caring for an adolescent client who has full-thickness burns on their leg. The client expresses concern about their future. Which of the following is a therapeutic response by the nurse?
Correct Answer: C
Rationale: The correct answer is C, "You're concerned about what will happen when you leave the hospital?" This response shows empathetic listening, acknowledges the client's feelings, and opens the door for further discussion. Option A dismisses the client's feelings. Option B implies the client shouldn't be concerned. Option D minimizes the client's emotions and focuses solely on physical aspects.
Question 4 of 5
A nurse is preparing to administer several medications via an NG tube to a client who is receiving a continuous tube feeding. Which of the following actions should the nurse take?
Correct Answer: A
Rationale: The correct answer is A: Flush the NG tube with 5 mL of sterile water for irrigation prior to administration. This action is important to ensure that the NG tube is clear and free of any residual formula or medication, preventing potential clogs or interactions. Flushing the tube with sterile water helps maintain the tube's patency and prevents any obstruction.
Summary of incorrect choices:
B: Mixing medications together in a single syringe can lead to drug interactions and inconsistent dosing.
C: Combining medications with the formula in the feeding bag can alter the medication's effectiveness and may lead to clogs in the tube.
D: Diluting each crushed medication with warm water may not effectively clear the tube and could still lead to clogs or interactions.
Question 5 of 5
A nurse in a mental health clinic is caring for an older adult client who has depression and has stopped taking their medication. The client tells the nurse, 'I want to die now that my partner is gone.' Which of the following responses should the nurse make?
Correct Answer: B
Rationale: Answer B is correct because it directly addresses the client's statement about wanting to die, which indicates suicidal ideation. By asking if the client has thought about harming themselves, the nurse is assessing the client's risk of self-harm and can then take appropriate actions to ensure the client's safety.
Answer A is incorrect as it focuses on the medication issue rather than the client's immediate safety. Answer C is incorrect as it shifts the focus away from the client's suicidal thoughts. Answer D is also incorrect as it doesn't address the immediate risk of self-harm and instead suggests discussing the feelings with the provider without assessing the client's safety first.