ATI RN
ATI RN Fundamentals 2023 I Questions
Extract:
Question 1 of 5
A nurse is preparing to administer medications to a client. At which of the following times should the nurse compare the medication administration record and the medication label? (Select all that apply.)
Correct Answer: A,D,E
Rationale: The correct times for the nurse to compare the medication administration record and the medication label are A, D, and E. A is correct because comparing them when preparing the medication dosage ensures the right medication is being administered. D is important when removing the medication from the drawer to verify it matches the record. E is crucial directly before administering to double-check accuracy.
Choice B is incorrect as reconciling controlled substances doesn't involve verifying specific medications.
Choice C at the end of the shift is not ideal as errors may have already occurred.
Question 2 of 5
A community health nurse is visiting an older adult client who recently moved into an assisted living apartment. Which of the following client statements indicates difficulty accepting their transition?
Correct Answer: B
Rationale:
Correct Answer: B
Rationale:
Choice B indicates difficulty accepting the transition as the client is isolating themselves from social activities due to perceived differences with other residents. This can lead to feelings of loneliness and reluctance to engage with the new community. In contrast, choices A, C, and D show the client adapting positively to the new environment by acknowledging benefits, following staff advice for safety, and finding alternative transportation solutions.
Summary:
Choice B stands out as the client's statement reflects potential social withdrawal, while the other choices demonstrate acceptance and adaptation to the changes in the assisted living setting.
Question 3 of 5
A nurse is caring for a client who is postoperative and is on bed rest. Which of the following actions should the nurse take to decrease the client’s risk of developing a pressure injury?
Correct Answer: C
Rationale: The correct answer is C: Ensure the client’s heels are not touching the mattress. This is important because pressure injuries commonly occur on bony prominences, such as the heels, due to prolonged pressure and friction. By ensuring the client’s heels are elevated off the mattress, the nurse can reduce the risk of pressure injury development in this area. Repositioning the client every 4 hours (choice
A) is important but may not specifically address the risk of pressure injury on the heels. Raising the head of the client’s bed to a 60° angle (choice
B) is more related to preventing aspiration in a postoperative client than preventing pressure injuries. Massaging the client’s bony prominences (choice
D) can actually increase the risk of skin breakdown due to friction and shearing forces.
Question 4 of 5
A nurse is collecting a blood pressure (BP) reading from a client who is sitting in a chair. The nurse determines that the client’s BP is 158/96 mm Hg. Which of the following actions should the nurse take?
Correct Answer: C
Rationale: The correct answer is C: Recheck the client's BP in her other arm for comparison. This is the best course of action to ensure accuracy of the BP reading. By rechecking the BP in the other arm, the nurse can determine if the initial reading was accurate or if there are any significant differences between the arms. This can help identify any potential issues such as arterial blockages or other underlying conditions affecting the BP.
Choice A is incorrect because the width of the BP cuff should be 40% of the upper arm circumference, not 50%.
Choice B is not necessary unless the client is showing signs of distress or discomfort, as it is important to keep the client in the same position for consistent readings.
Choice D is unnecessary unless there are specific reasons to suspect inaccurate readings or if the client's condition changes significantly.
In summary, rechecking the BP in the other arm is the most appropriate action to verify the accuracy of the initial reading and ensure the client's safety.
Question 5 of 5
A nurse is caring for a client who has dysphagia. When assisting the client during breakfast, which of the following actions by the client indicates the nurse should intervene?
Correct Answer: B
Rationale: The correct answer is B. When a client has dysphagia, drinking thickened liquids with a straw can increase the risk of aspiration because the liquid may move too quickly through the straw. This can lead to choking or aspiration pneumonia.
Choices A, C, and D are all appropriate actions for a client with dysphagia. Adjusting the bed to 90° helps with swallowing, tucking the chin can prevent aspiration, and taking breaks while eating can reduce the risk of choking.