ATI RN
ATI Fundamentals 2023 Retake 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. The collar provides stability and security, reducing the risk of complications such as airway obstruction. It also allows for easy adjustment and removal if needed.
A: Wearing clean gloves is important, but it is not directly related to tracheostomy care.
B: Hydrogen peroxide is not recommended for cleansing the skin around the stoma as it can be irritating and drying to the skin.
C: Placing a gauze pad under the flanges is not necessary and may increase the risk of infection or skin breakdown.
Overall, option D is the most appropriate action for tracheostomy care.
Question 2 of 5
A nurse is assessing a client who has left-sided weakness following a stroke. Which of the following findings is the nurse's priority?
Correct Answer: B
Rationale: The correct answer is B: The client coughs frequently while eating. This is the priority finding because it indicates a risk of aspiration, which is a life-threatening complication post-stroke. Aspiration can lead to pneumonia and respiratory distress. Addressing this issue promptly is crucial to prevent further complications. The other choices are not as critical. A high blood pressure (option
A) can be managed with medication adjustments. Leaning to the left side (option
C) may be due to the weakness and can be addressed with positioning. Consuming only 25% of meals (option
D) is concerning but not as immediately life-threatening as the risk of aspiration.
Question 3 of 5
A nurse is caring for an adolescent client who has full-thickness burns on their leg. The client expresses concern about their future. Which of the following is a therapeutic response by the nurse?
Correct Answer: C
Rationale: The correct answer is C, "You're concerned about what will happen when you leave the hospital?" This response shows empathetic listening, acknowledges the client's feelings, and opens the door for further discussion. Option A dismisses the client's feelings. Option B implies the client shouldn't be concerned. Option D minimizes the client's emotions and focuses solely on physical aspects.
Question 4 of 5
A nurse is planning care for a client who is immobile. Which of the following actions should the nurse include in the plan of care?
Correct Answer: A
Rationale: The correct answer is A: Use trochanter rolls beside the client's legs. Trochanter rolls help prevent external rotation of the hips and maintain proper alignment of the legs, reducing the risk of hip dislocation and pressure ulcers. Placing the client's arms at their sides (
B) can restrict circulation and cause discomfort. Logrolling (
C) is not typically done every 4 hours and is more appropriate for specific situations. Crossing the client's ankles (
D) can lead to pressure injuries and compromise circulation.
Question 5 of 5
A charge nurse is observing a staff nurse performing a wound irrigation for a client who has a pressure injury. Which of the following actions by the staff nurse indicates an understanding of the procedure?
Correct Answer: B
Rationale: The correct answer is B: Uses a syringe with a catheter for wound irrigation. This action indicates an understanding of the procedure because using a syringe with a catheter allows for controlled and precise irrigation of the wound, ensuring thorough cleaning and removal of debris. It also helps prevent cross-contamination and promotes wound healing.
Incorrect choices:
A: Using one pair of gloves for dressing removal and irrigation increases the risk of contamination and infection.
C: Administering an analgesic medication before irrigation is not a standard practice and does not demonstrate understanding of the procedure.
D: Refrigerating the solution before irrigation is unnecessary and may cause discomfort to the client.