ATI RN
ATI RN Fundamentals 2023 Exam 5 Questions
Extract:
Question 1 of 5
A nurse is preparing to lift a box of personal items off the floor in a client's room. Which of the following actions should the nurse take to help prevent injury when lifting the box?
Correct Answer: B
Rationale: Bending at the waist to pick up the box is not recommended as it can put excessive strain on the lower back. Proper lifting techniques involve bending at the knees and hips, not the waist, to use the stronger muscles of the legs and reduce the risk of back injury. This method helps maintain the natural curve of the spine and distributes the load more evenly. When lifting the box, keeping it close to the body is the most appropriate action. This technique reduces the lever arm distance, thereby decreasing the strain on the back muscles and spine. Holding the load close to the body ensures better control and stability, making it easier to lift and carry the box safely. Keeping the feet close together when lifting a box is not advisable. A wide stance, with feet shoulder-width apart, provides better balance and stability. This position allows for a more secure lift and reduces the risk of losing balance or straining muscles during the lifting process. Relaxing the abdominal muscles to prevent straining the back is incorrect. Engaging the core muscles, including the abdominals, provides additional support to the spine and helps maintain proper posture during lifting. Tightening the abdominal muscles can help stabilize the torso and reduce the risk of back injury.
Question 2 of 5
A nurse is caring for a client who has an extracellular fluid volume deficit. Which of the following findings should the nurse expect?
Correct Answer: C
Rationale: Edema and distended neck veins indicate fluid overload, not deficit. Postural hypotension occurs due to reduced blood volume, causing dizziness upon standing. Tachycardia, not bradycardia, is expected as a compensatory response to fluid loss.
Question 3 of 5
A nurse enters a client's room and finds the client on the floor having a seizure. Which of the following actions should the nurse take?
Correct Answer: C
Rationale: Lifting the client to the bed with assistance is not recommended during a seizure. Moving the client can increase the risk of injury to both the client and the nurse. The primary focus should be on ensuring the client's safety by preventing injury from nearby objects and allowing the seizure to run its course. Turning the client onto their back is not advisable during a seizure. This position can increase the risk of airway obstruction and aspiration. Instead, the client should be turned onto their side to maintain an open airway and allow any secretions to drain from the mouth, reducing the risk of aspiration. Clearing the nearby area of furniture is the most appropriate action. This helps to prevent the client from injuring themselves on hard or sharp objects during the seizure. Ensuring a safe environment is a key priority in managing a seizure, as it minimizes the risk of physical harm. Placing a tongue depressor in the client's mouth is an outdated and dangerous practice. It can cause injury to the client's teeth, mouth, or airway. There is also a risk of the client biting down and breaking the depressor, leading to choking hazards. Modern seizure management guidelines strongly advise against placing any objects in the client's mouth during a seizure.
Question 4 of 5
A nurse is completing discharge teaching about ostomy care with a client who has a new stoma. Which of the following instructions should the nurse include in the teaching? (Select all that apply.)
Correct Answer: A,E
Rationale: Cutting the pouch opening 1/8 inch larger ensures a proper fit, preventing skin irritation. Using gauze is a practical tip but not a core instruction. A purple-blue stoma indicates poor blood flow, not healing, and requires medical attention. Povidone-iodine is too harsh; mild soap and water are recommended. Emptying the pouch at one-third full prevents leaks and maintains hygiene.
Question 5 of 5
A nurse is planning care for a client who has a seizure disorder. Which of the following actions should the nurse include in the client's plan of care?
Correct Answer: C
Rationale: Having a padded tongue blade available at the client's bedside is not recommended for seizure management. Inserting any object into a patient's mouth during a seizure can cause injury to the teeth, gums, or jaw. Current guidelines advise against placing anything in the mouth of a person having a seizure. Instead, focus should be on ensuring the patient's safety by turning them on their side to maintain an open airway and prevent aspiration. Keeping the four side rails down when the client is in bed is not advisable for a client with a seizure disorder.
To prevent injury during a seizure, it is important to keep the side rails up and padded. This helps prevent the client from falling out of bed and sustaining injuries. Additionally, the bed should be kept in its lowest position to minimize the risk of injury from falls. Keeping suction equipment available in the client's room is crucial for managing a client with a seizure disorder. During a seizure, there is a risk of aspiration due to excessive salivation or vomiting. Having suction equipment readily available allows the nurse to quickly clear the client's airway, reducing the risk of aspiration and ensuring the client can breathe properly. Having wire cutters available at the client's bedside is not typically necessary for managing a seizure disorder. They are sometimes mentioned in the context of clients with Vagus Nerve Stimulators (VNS), where wire cutters might be used in an emergency to cut the VNS wire. However, this is a rare situation and not a standard precaution for all clients with seizure disorders.