ATI RN
ATI RN Fundamentals 2023 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: D
Rationale:
Correct
Answer: D
Rationale: Cutting the old ties after securing the new ties ensures that the client's airway remains stable throughout the procedure. If the old ties are cut before securing the new ties, there is a risk of accidental decannulation, leading to potential airway compromise. This step-by-step approach prioritizes patient safety and prevents unnecessary risks during the tracheostomy tie change.
Summary:
A: Allowing space for three fingers under the ties is important for proper fit but not the immediate action needed during the tie change.
B: Using a quick-release knot may be helpful for easy removal in emergencies but is not the primary concern during the tie change.
C: Extending the client's neck may help with visualization but is not essential for securing the ties.
D: Cutting the old ties after securing the new ties is the correct action to maintain airway stability.
E, F, G: No information provided.
Question 2 of 5
A nurse is planning care for a client who has a new prescription for parenteral nutrition (PN) in 20% dextrose and fat emulsions. Which of the following is an appropriate action to include in the plan of care?
Correct Answer: C
Rationale:
Correct
Answer: C. Prepare the client for a central venous line.
Rationale: PN with high osmolarity and high glucose concentration can cause vein irritation and damage peripheral veins.
Therefore, the use of a central venous line is appropriate to minimize the risk of complications like phlebitis and thrombophlebitis.
Incorrect
Choices:
A: Obtaining a random blood glucose daily is important for monitoring blood glucose levels in clients receiving PN, but it does not address the need for a central venous line.
B: Changing the PN infusion bag every 48 hours is a standard practice to prevent contamination but does not address the need for a central venous line.
D: Administering the PN and fat emulsion separately is not necessary as they are often combined in one infusion for convenience and efficiency.
Question 3 of 5
A nurse is caring for a client who reports that she has insomnia. Which of the following interventions is appropriate for the nurse to recommend?
Correct Answer: C
Rationale: The correct answer is C: Eat a light carbohydrate snack before bedtime. Carbohydrates can help increase the production of serotonin, a neurotransmitter that promotes relaxation and sleep. Consuming a light carbohydrate snack before bedtime can help regulate blood sugar levels and promote a sense of calmness conducive to falling asleep.
Choice A (Drink a cup of hot cocoa) contains caffeine which can interfere with sleep.
Choice B (Exercise 1 hr before bedtime) can increase alertness and make it harder to fall asleep.
Choice D (Take a 30-min nap daily) can disrupt the sleep-wake cycle and make it difficult to sleep at night.
Question 4 of 5
A nurse is caring for a client who has left lower-lobe atelectasis. In which of the following positions should the nurse place the client for postural drainage?
Correct Answer: B
Rationale: The correct answer is B: Right lateral in Trendelenburg position. Placing the client in a right lateral position helps target the left lower-lobe atelectasis by allowing drainage of secretions from that specific area. Trendelenburg position further aids in promoting drainage due to the head being lower than the feet, assisting gravity in moving secretions. Other options are incorrect as they do not provide the specific positioning needed to target the left lower-lobe atelectasis effectively. Side-lying with the right side of the chest elevated would not facilitate drainage from the affected lobe. Placing the client prone with pillows under the lower extremities or supine in low-Fowler's position would not target the specific area requiring drainage.
Question 5 of 5
A nurse is caring for a client who has a terminal illness. The client states, 'I am not giving up. I want as much treatment as possible.' Which of the following responses should the nurse make?
Correct Answer: C
Rationale: The correct answer is C: "I will contact your provider to discuss your options." This response demonstrates the nurse's commitment to advocating for the client's wishes while ensuring appropriate communication with the healthcare provider to explore available treatment options. It respects the client's autonomy and decision-making process.
Incorrect
Choices:
A: Hospice care may not align with the client's current wishes for aggressive treatment.
B: While important, this response does not address the client's desire for treatment options.
D: This response may not be in line with the client's current mindset and can be seen as dismissive.
Overall, choice C is the most appropriate as it acknowledges the client's wishes and facilitates informed decision-making.