ATI RN
ATI RN Fundamentals 2023 Questions
Extract:
Question 1 of 5
A nurse is preparing to provide tracheostomy care for a client. Which of the following actions should the nurse plan to take?
Correct Answer: D
Rationale: The correct answer is D: Secure the tracheostomy in place with a collar that has hook-and-loop fasteners. This is important to prevent accidental dislodgement of the tracheostomy tube, ensuring proper airway patency. Using a collar with hook-and-loop fasteners allows for secure but adjustable placement, accommodating variations in neck size and minimizing the risk of pressure injuries. A: Wearing clean gloves during inner cannula cleaning is essential for infection control but not directly related to securing the tracheostomy. B: Placing a gauze pad under the flanges helps absorb secretions but does not directly address securing the tracheostomy. C: Cleansing the skin with hydrogen peroxide can be too harsh and irritating; a milder solution like saline is preferred.
Question 2 of 5
A nurse is teaching a group of newly licensed nurses about the Braden scale. Which of the following responses by a newly licensed nurse indicates an understanding of the teaching?
Correct Answer: A
Rationale: The correct answer is A: "The scale measures six elements." The Braden scale indeed assesses six elements: sensory perception, moisture, activity, mobility, nutrition, and friction/shear. This response shows an understanding of the scale's components.
Choice B is incorrect because the client's age is not a factor in the Braden scale assessment.
Choice C is incorrect as a higher score on the Braden scale indicates a lower pressure injury risk.
Choice D is incorrect because each element on the Braden scale has a range from one to four points, not one to five.
Question 3 of 5
A nurse is preparing to administer packed RBCs to a client who has a low hemoglobin level. Which of the following actions should the nurse take prior to the start of the infusion?
Correct Answer: D
Rationale: The correct answer is D: Check the blood product's compatibility with the client's blood type. This step is crucial to prevent a transfusion reaction, as administering incompatible blood can be life-threatening. The nurse should verify the blood product against the client's blood type and Rh factor to ensure compatibility.
A: Priming the IV tubing with lactated Ringer's is not necessary before administering packed RBCs and does not ensure the blood product's compatibility.
B: Confirming the client's identity with the blood bank technician is important but does not directly relate to ensuring the blood product's compatibility.
C: Checking for a small gauge IV catheter is important for infusion, but it is not directly related to ensuring the blood product's compatibility.
Overall, the priority before administering packed RBCs is to confirm compatibility with the client's blood type to prevent adverse reactions.
Question 4 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: B
Rationale:
Correct Answer: B - Ensure the client's heels are not touching the mattress.
Rationale: Keeping the client's heels off the mattress reduces pressure on this vulnerable area, decreasing the risk of developing pressure injuries. Pressure injuries commonly occur on bony prominences like the heels, making option A incorrect. Raising the head of the bed does not directly address pressure injury prevention, so option C is not the best choice. Repositioning every 4 hours is important but may not be sufficient to prevent pressure injuries, making option D less effective than ensuring the heels are off the mattress.
Question 5 of 5
A nurse is providing teaching to a client about reducing the adverse effects of immobility. Which of the following statements by the client indicates an understanding of the teaching?
Correct Answer: A
Rationale:
Correct Answer: A
Rationale: Performing ankle and knee exercises every hour helps prevent muscle atrophy and improve circulation, reducing adverse effects of immobility. This promotes joint mobility and prevents blood clots.
Choice B: Having a partner help change positions every 4 hours may not be frequent enough to prevent complications of immobility.
Choice C: Removing antiembolic stockings while in bed can increase the risk of blood clots as they are meant to promote circulation.
Choice D: Holding breath when rising from a sitting position can lead to dizziness and falls, not addressing the adverse effects of immobility.