ATI RN
ATI RN Fundamentals Updated 2023 Exam Questions
Extract:
Question 1 of 5
A nurse is preparing a sterile field to assist with suturing a client's laceration. Which of the following actions should the nurse plan to take?
Correct Answer: C
Rationale: The correct answer is C: Hold the bottle of sterile solution so that the label is facing the palm of the hand. This action is important to maintain the sterility of the solution. By holding the bottle with the label facing the palm, the nurse ensures that the solution does not come into contact with the outside of the bottle, which could introduce contaminants. This practice helps prevent the introduction of microorganisms into the sterile field, reducing the risk of infection for the client.
Incorrect options:
A: Applying sterile gloves before opening the bottle of sterile solution is not necessary for preparing the sterile field.
B: Placing the lid of the sterile solution bottle face down on the sterile drape can lead to contamination.
D: Pouring the sterile solution from a height of 20 cm (8 in) above the sterile bowl may create splashing and increase the risk of contamination.
Question 2 of 5
A nurse is delegating client care tasks to an assistive personnel. Which of the following tasks should the nurse delegate?
Correct Answer: B
Rationale: The correct answer is B: Performing a simple dressing change. This task can be safely delegated to an assistive personnel as it is within their scope of practice and does not require specialized nursing knowledge or assessment skills. The nurse should provide clear instructions and supervise the task. Tasks such as inserting an NG tube (
A) require specialized training and should be performed by a licensed nurse. Evaluating healing of an incision (
C) involves assessment and interpretation of findings, which is a nursing responsibility. Changing IV tubing (
D) involves potential risks and requires nursing assessment and intervention.
Question 3 of 5
A nurse in an emergency department is assessing a client who reports right lower quadrant pain, nausea, and vomiting for the past 48 hr. Which of the following actions should the nurse take first?
Correct Answer: D
Rationale: The correct answer is D: Auscultate bowel sounds. This is the first action the nurse should take as it can provide crucial information about the client's condition, particularly in suspected appendicitis. Absence of bowel sounds in the right lower quadrant may indicate an inflamed appendix, requiring immediate medical attention. Administering an antiemetic (choice
A) or pain medication (choice
B) without assessing the bowel sounds first could mask important symptoms. Palpating the abdomen (choice
C) can potentially worsen the client's condition if appendicitis is present.
Therefore, auscultating bowel sounds is the priority to guide further assessment and intervention.
Question 4 of 5
A nurse is reviewing a client's intake and output and notes the following: 0.9% sodium chloride 600 mL IV infusion, cefazolin 250 mg in dextrose 5% in water 100 mL intermittent IV bolus, 200 mL emesis, 40 mL voided urine, and 20 mL urine from straight catheterization. The nurse should record the client's net fluid intake as how many mL? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
Correct Answer: 440
Rationale:
To calculate the net fluid intake, we need to add all fluid inputs (IV fluids and oral intake) and subtract all fluid outputs (emesis, voided urine, catheterized urine).
IV fluids: 600 mL + 100 mL = 700 mL
Oral intake: 250 mg cefazolin in 100 mL = 100 mL
Total input = 700 mL + 100 mL = 800 mL
Total output = 200 mL (emesis) + 40 mL (voided urine) + 20 mL (catheterized urine) = 260 mL
Net fluid intake =
Total input -
Total output = 800 mL - 260 mL = 540 mL
Therefore, the correct answer is 540 mL, rounded to the nearest whole number, which is 540 mL. Other choices are incorrect as they do not align with the calculations based on the given inputs and outputs.
Question 5 of 5
A nurse is providing teaching to a client who is at risk for thrombus formation. Which of the following statements made by the client indicates an understanding of the teaching?
Correct Answer: C
Rationale: The correct answer is C: "I should limit the time that I spend sitting in a chair." This statement shows an understanding of the teaching because prolonged sitting increases the risk of thrombus formation. By limiting sitting time, the client can promote circulation and reduce the risk of blood clots.
Other choices are incorrect:
A: Keeping legs crossed can impede blood flow, increasing the risk of thrombus formation.
B: Massaging legs when they hurt may not prevent thrombus formation and could potentially dislodge a clot.
D: Performing leg exercises once every 4 hours may not be frequent enough to prevent blood clots.