ATI RN
ATI RN Fundamentals 2023 II Questions
Extract:
Question 1 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: Dilute each crushed medication with warm water. When administering medications via an NG tube along with tube feeding, it is crucial to dilute each crushed medication with warm water to prevent clogging of the tube and ensure proper absorption. Diluting medications helps prevent blockages and ensures consistent delivery.
Choices B, C, and D are incorrect as flushing with sterile water, combining medications with formula, and mixing in a single syringe can lead to tube occlusion, inconsistent dosing, and potential drug interactions.
Question 2 of 5
A nurse is collaborating with a risk management team about potential legal issues involving client care. The nurse should identify that which of the following situations is an example of negligence?
Correct Answer: A
Rationale:
Correct Answer: A. A nurse administers a medication without first identifying the client.
Rationale:
1. Negligence involves failing to provide care that meets the standard of care expected in a particular situation.
2. Administering medication without first identifying the client violates the standard of care and can lead to serious harm.
3. Proper identification of the client is a fundamental safety measure to ensure correct medication administration.
4. Failure to identify the client can result in medication errors, adverse reactions, and potential harm to the client.
Summary of Incorrect
Choices:
B. Preventing a client from leaving the facility may be related to safety concerns but does not directly involve negligence.
C. Beginning a blood transfusion without consent is a violation of the client's rights but not a clear example of negligence.
D. Discussing client care in a public area may breach confidentiality but does not directly relate to negligence in client care.
Question 3 of 5
A charge nurse is observing a staff nurse performing a wound irrigation for a client who has a pressure injury. Which of the following actions by the staff nurse indicates an understanding of the procedure?
Correct Answer: D
Rationale: The correct answer is D because administering an analgesic medication 5 minutes before starting wound irrigation indicates an understanding of the procedure. Pain management is crucial to ensure client comfort during wound care.
Choice A is incorrect as a syringe with a catheter is not typically used for wound irrigation.
Choice B is incorrect as refrigerating the solution is unnecessary and may cause discomfort to the client.
Choice C is incorrect as using one pair of gloves for both dressing removal and irrigation increases the risk of cross-contamination.
Question 4 of 5
To ensure client safety, a nurse manager is planning to observe a newly licensed nurse perform a straight catheterization on a client. In which of the following roles is the nurse manager functioning?
Correct Answer: D
Rationale: The correct answer is D: Client advocate. The nurse manager is functioning in the role of a client advocate by ensuring the safety of the client during the straight catheterization procedure. Advocacy involves protecting the client's rights, promoting their well-being, and ensuring they receive safe and appropriate care. The other choices are incorrect because:
A) Case manager focuses on coordinating care and resources for the client,
B) Client educator involves providing information and teaching the client about their care, and
C) Client care provider refers to directly providing hands-on care to the client, which is not the primary role of the nurse manager in this scenario.
Question 5 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: A
Rationale:
Correct Answer: A - Ensure the client's heels are not touching the mattress.
Rationale:
1. Pressure injuries commonly occur at bony prominences like heels.
2. When heels are in contact with the mattress for a prolonged period, it can lead to compromised blood flow and tissue damage.
3. Elevating the heels off the mattress reduces pressure and friction, decreasing the risk of pressure injury.
Summary of other choices:
B. Repositioning every 4 hr helps prevent pressure injuries but focusing on heel offloading is more critical.
C. Raising the head of the bed does not directly address the pressure on the heels.
D. Massaging bony prominences can actually increase the risk of pressure injury by causing friction and shearing forces.