ATI RN
ATI RN Fundamentals 2023 Exam 5 Questions
Extract:
Question 1 of 5
A nurse is preparing to assess a client's carotid arteries. Which of the following actions should the nurse plan to take?
Correct Answer: B
Rationale: Placing the client in a high-Fowler's position during the assessment is not necessary for assessing the carotid arteries. While this position can be useful for other assessments, it is not specifically required for carotid artery evaluation. The client can be in a seated or supine position with the head slightly elevated. Auscultating each carotid artery with the bell of the stethoscope is the most appropriate action. This technique allows the nurse to listen for bruits, which are abnormal sounds indicating turbulent blood flow due to partial obstruction or narrowing of the artery. Using the bell of the stethoscope is crucial because it is better suited for detecting low-pitched vascular sounds. Palpating the carotid arteries simultaneously is not recommended. Doing so can significantly reduce blood flow to the brain, potentially causing dizziness or fainting. Instead, each carotid artery should be palpated individually to assess the amplitude and contour of the pulse without compromising circulation. Massaging the carotid artery while assessing the client is inappropriate and potentially dangerous. Massaging the carotid artery can stimulate the carotid sinus, leading to a reflex drop in heart rate and blood pressure, which can cause syncope (fainting). This action should be avoided during assessment.
Question 2 of 5
A nurse is assessing a client whose therapy has included bed rest for several weeks. Which of the following findings should the nurse identify as the priority?
Correct Answer: C
Rationale: Increased heart rate during physical activity can be a common finding in clients who have been on bed rest for an extended period. This is due to deconditioning of the cardiovascular system. While it is important to monitor and address, it is not the most immediate concern compared to other potential complications. Loss of appetite is another common issue in clients who have been on prolonged bed rest. It can lead to nutritional deficiencies and weight loss, which are significant concerns. However, it is not as urgent as other findings that might indicate more acute complications. Left lower extremity tenderness is the most critical finding and should be identified as the priority. This symptom can indicate deep vein thrombosis (DVT), a serious condition that can lead to life-threatening complications such as pulmonary embolism if not promptly addressed. DVT is a common risk for clients who have been immobile for extended periods, making it a top priority for immediate intervention. Musculoskeletal weakness is expected in clients who have been on bed rest for several weeks. It results from muscle atrophy and deconditioning. While it is an important issue to address through rehabilitation and physical therapy, it does not pose an immediate threat to the client's life compared to the risk of DVT.
Question 3 of 5
A staff nurse is teaching a newly hired nurse how to complete an informed consent document for a client. The staff nurse should include that the nurse's signature on the form confirms which of the following requirements? (Select all that apply.)
Correct Answer: B,C,D
Rationale: Language isn’t confirmed by the signature; interpreters can be used. The nurse’s signature verifies the client signed in their presence, was not coerced, and has legal authority (e.g., is competent). Mental health conditions don’t preclude consent if capacity is intact.
Question 4 of 5
A nurse is caring for a client who has a traumatic brain injury and needs to relearn how to use eating utensils. The nurse should refer the client to which of the following members of the interprofessional team?
Correct Answer: B
Rationale: Physical therapists primarily focus on improving a patient's physical function, mobility, and strength. They work on activities such as walking, balance, and coordination. While they play a crucial role in the rehabilitation of clients with traumatic brain injuries, their expertise is not specifically centered on activities of daily living (ADLs) like using eating utensils. Occupational therapists specialize in helping clients regain the ability to perform ADLs, which include tasks such as eating, dressing, and bathing. They use therapeutic techniques to improve fine motor skills, coordination, and cognitive function, which are essential for relearning how to use eating utensils. Their goal is to enhance the client's independence and quality of life by enabling them to perform everyday activities. Speech-language pathologists focus on communication disorders and swallowing difficulties. They work with clients to improve speech, language, and cognitive-communication skills. While they are essential for addressing issues related to speech and swallowing, they do not typically focus on the motor skills required for using eating utensils. Social workers provide support and resources to help clients and their families cope with the emotional, social, and financial aspects of a traumatic brain injury. They assist with discharge planning, accessing community resources, and providing counseling. However, they do not provide direct rehabilitation services related to the use of eating utensils.
Question 5 of 5
A nurse is considering placing wrist restraints on a client who has cognitive deficits and has pulled out their IV catheter. Before using wrist restraints, which of the following actions must the nurse take first?
Correct Answer: D
Rationale: Documenting the indications for using wrist restraints is an important step in the process, but it is not the first action the nurse should take. Documentation ensures that there is a clear rationale for the use of restraints and helps in maintaining legal and ethical standards. However, before documenting, the nurse must explore and attempt less restrictive alternatives to ensure that restraints are truly necessary. Obtaining a prescription for restraints from the provider is a crucial step, as restraints should only be used with a valid order from a healthcare provider. This ensures that the use of restraints is medically justified and that the provider is aware of the client's condition. However, before seeking a prescription, the nurse must first attempt less restrictive alternatives to manage the client's behavior. Explaining the procedure to the client and their family is an important step in obtaining informed consent and maintaining transparency. However, it should be done after the nurse has determined that less restrictive alternatives are not effective and that restraints are necessary. Attempting less restrictive alternatives is the first action the nurse must take. This approach aligns with ethical and legal guidelines that emphasize the use of the least restrictive measures to ensure the client's safety. Alternatives may include verbal de-escalation, environmental modifications, or the use of less restrictive devices. Only if these measures fail should the nurse consider using restraints.