ATI Fundamentals 2023 Retake

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?

A. Wear clean gloves while cleaning the inner cannula.B. Cleanse the skin around the stoma with full-strength hydrogen peroxide.C. Cut a 4 inch × 4 inch (10 cm × 10 cm) gauze pad to place under the flanges of the tracheostomy tube.D. Secure the tracheostomy in place with a collar that has hook-and-loop fasteners.

Correct Answer: D

Rationale: Securing with a hook-and-loop collar (
D) ensures stability safely. Clean gloves (
A) risk infection (sterile needed), hydrogen peroxide (
B) irritates, and cutting gauze (
C) risks fiber inhalation.

Question 2 of 5

A nurse is planning to change a client's tracheostomy ties. Which of the following actions should the nurse take?

A. Allow space for three fingers under the ties when securing.B. Cut the old ties after the new ties are secured.C. Use a quick-release knot to secure the ties.D. Extend the client's neck while securing the ties.

Correct Answer: B

Rationale: Cutting old ties after securing new ones (
B) prevents tube dislodgement. Three fingers (
A) is too loose, quick-release (
C) is optional, and neck extension (
D) risks discomfort.

Question 3 of 5

A nurse is assessing a client who has cirrhosis. Which of the following findings indicates the client is experiencing a fluid volume excess?

A. Dependent edemaB. Increased serum sodiumC. Thready pulseD. Increased thirst

Correct Answer: A

Rationale: Dependent edema (
A) signals fluid excess in cirrhosis. High sodium (
B) and thirst (
D) suggest deficit, and thready pulse (
C) isn’t specific.

Question 4 of 5

A nurse in a mental health clinic is caring for an older adult client who has depression and has stopped taking their medication. The client tells the nurse, 'I want to die now that my partner is gone.' Which of the following responses should the nurse make?

A. Why did you stop taking your medication?'B. Have you thought about harming yourself?'C. Tell me more about your partner.'D. You should discuss these feelings with your provider.'

Correct Answer: B

Rationale: Have you thought about harming yourself?' (
B) directly addresses suicidal ideation, prioritizing safety per mental health protocols. Medication cessation (
A) and partner details (
C) are secondary, and referral (
D) delays immediate assessment.

Question 5 of 5

A nurse is preparing to set up a sterile field. Which of the following actions should the nurse take?

A. Open the outermost flap of the sterile kit toward the body.B. Hold bottles of sterile solution with the label in the palm of the hand.C. Pour liquids into containers outside the sterile field.D. Place the sterile field at the level of the nurse's hips.

Correct Answer: B

Rationale: Holding bottles label-in-palm (
B) prevents drips contaminating the field. Flap toward body (
A) risks contamination, pouring outside (
C) breaks sterility, and hip level (
D) is too low (waist or above).

ATI Fundamentals 2023 Retake | Nurselytic

Nurselytic

ATI RN

ATI RN