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 providing discharge teaching about safety considerations to an older adult client who lives at home. The client has heart failure and a new prescription for hydrochlorothiazide. Which of the following statements by the client indicates an understanding of the teaching?
Correct Answer: C
Rationale: The correct answer is C: "I will leave a light on in my bathroom at night." This statement indicates an understanding of safety considerations for an older adult with heart failure taking hydrochlorothiazide. Leaving a light on in the bathroom at night can prevent falls, as older adults are at higher risk due to medication side effects like dizziness from hydrochlorothiazide. Option A is incorrect as regular weight monitoring is crucial for heart failure but should be done more frequently than once weekly. Option B is incorrect as hydrochlorothiazide is typically taken in the morning to avoid frequent urination at night. Option D is incorrect as taking a hot bath before bed can cause dehydration and affect blood pressure, which is not recommended for someone with heart failure.
Question 3 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: C
Rationale: The correct answer is C. Negligence occurs when a nurse fails to adhere to the standard of care, resulting in harm to the client. Administering medication without identifying the client violates the standard protocol, risking patient safety. Option A relates to lack of informed consent, not negligence. Option B involves restraint, not negligence. Option D pertains to confidentiality breach, not negligence. Thus, option C best exemplifies negligence in client care.
Question 4 of 5
A nurse is performing an eye assessment for a newly admitted client. Which of the following findings should the nurse expect?
Correct Answer: A
Rationale: The correct answer is A: Eyelashes that curl slightly outward. This is an expected finding in an eye assessment as normal eyelashes typically curve slightly outward. Eyelids blinking involuntarily (
B) is a normal physiological response, but the rate mentioned is too high. Pupils (
C) are normally 3 to 4 mm in diameter, not 8 to 9 mm. Corneas with an opaque appearance (
D) suggest a potential issue like corneal edema.
Question 5 of 5
A nurse is teaching a client who has decreased mobility about passive range-of-motion exercises. Which of the following statements should the nurse make?
Correct Answer: C
Rationale: The correct answer is C: "I will repeat these movements 3 to 5 times." This is the appropriate statement because passive range-of-motion exercises should be repeated multiple times to maintain joint mobility without causing excessive stress on the joints. Option A is incorrect because moving the joints to the point of mild pain can cause discomfort and potential harm. Option B is incorrect as moving the joints quickly may lead to strain or injury. Option D is incorrect because passive range-of-motion exercises are usually performed multiple times throughout the day to prevent joint stiffness.