ATI RN
ATI RN Fundamentals 2023 II Questions
Extract:
Question 1 of 5
A nurse is preparing to reposition a client who has a lower back injury. Which of the following actions should the nurse take?
Correct Answer: D
Rationale: The correct answer is D: Roll the client as one unit in a smooth, continuous motion. This is the correct action to prevent any unnecessary strain or injury to the client's lower back. Rolling the client as one unit maintains the alignment of the spine and minimizes twisting movements that could exacerbate the injury. Placing the client's arms at their sides (
A) is not as crucial as maintaining proper spinal alignment. Placing the client on the side of the bed nearest the direction they will be turned (
B) does not ensure proper alignment during repositioning. Flexing the client's knees (
C) may not be necessary if the client can be rolled smoothly. Overall, rolling the client as one unit is the safest and most effective method for repositioning a client with a lower back injury.
Extract:
Exibit 1
Medication Administration Record 0800:
Amoxicillin 500 mg PC every 8 hr
Exibit 2
Nurses' Notes
0800:
Antibiotic administered as prescribed.
Bilateral breath sounds clear and present throughout
0830
Client reports itching over the chest area and has urticaria over chest and trunk
Client states tongue feels swollen.
Bilateral breath sounds with scattered wheezing upon auscultation.
Exibit 3
Vital Signs
0800:
Temperature 37.6° C (99.7° F)
Blood pressure 108/56 mm Hg Heart rate 66/min Respiratory rate 18/min
Pulse oximetry 97% on room air
0830
Temperature 37.5° C (99.5° F)
Blood pressure 88/56 mm Hg
Heart rate 104/min
Respiratory rate 24/min
Pulse oximetry 93% on room air
Question 2 of 5
A nurse is caring for a client. Select the 4 findings that require immediate follow-up.
Correct Answer: B,C,D,E
Rationale: The correct findings that require immediate follow-up are breath sounds, blood pressure, heart rate, and swollen tongue. Breath sounds are essential to assess respiratory status. Blood pressure and heart rate indicate cardiovascular function. A swollen tongue could indicate an allergic reaction or airway compromise. Temperature, urticaria, and an absent option do not necessarily require immediate follow-up as they may not directly impact the client's immediate health status.
Extract:
Exibit 1
Provider Prescriptions
Day 4, 1500:
Discharge prescriptions:
Cephalexin 500 mg PO every 6 hr for 5 days Prednisone 40 mg PO daily for 5 days Home oxygen 3 L/min via nasal cannula
Exibit 2
Vital Signs
Day 1, 1100:
Temperature 39.1° C (102.4° F) Pulse rate 102/min Respiratory rate 26/min
Blood pressure 122/80 mm Hg Oxygen saturation 86% on room air Weight 90.7 kg (200 lb)
Day 2, 1200:
Temperature 38° C (100.4° F) Pulse rate 100/min Respiratory rate 22/min
Blood pressure 120/74 mm Hg
Oxygen saturation 88% on nasal cannula at 2 L/min Day 3, 1200:
Température 37.2° C (98.9" F) Pulse rate 90/min
Respiratory rate 20/min
Blood pressure 120/72 mm Hg
Exibit 3
Medication Administration Record
Day 1, 1500:
Cefazolin 500 mg every 12 hr IV Dexamethasone 15 mg every 6 hr IV Day 3, 1200:
Discontinue dexamethasone 15 mg every 6 hr IV Prednisone 40 mg PO daily
Day 4, 1500:
Discontinue cefazolin 500 mg every 12 hr IV
Question 3 of 5
A nurse is caring for a client who has pneumonia. Which of the following instructions should the nurse include in the teaching? (Select all that apply.)
Correct Answer: D,E,F
Rationale:
Correct Answer: D, E, F
Rationale:
D: Steroid medication should be taken in the morning - Steroid medication is typically taken in the morning to align with the body's natural cortisol production.
E: The steroid dose will decrease each day - Steroid therapy is usually tapered off gradually to prevent withdrawal symptoms.
F: Ensure the oxygen delivery system is at least 8 feet from any heat source - This is important to prevent the risk of fire or explosion.
Incorrect
Choices:
A: Store the oxygen cylinder wrench with the oxygen tank - This is incorrect as the wrench should be stored separately for easy access during emergencies.
B: Antibiotic therapy should be taken for 10 days - The duration of antibiotic therapy may vary depending on the specific antibiotic and the severity of the infection. It is not always 10 days.
C: Adjust the oxygen flow rate as needed to ease breathing - The oxygen flow rate should be set according to the healthcare provider's instructions and not adjusted arbitrarily.
G
Extract:
Question 4 of 5
A nurse is caring for a client who has a colostomy. Which of the following actions should the nurse take?
Correct Answer: D
Rationale: The correct answer is D: Ensure the pouch is 0.32 cm (1/8 in) larger than the stoma. This is important to prevent irritation and damage to the stoma. If the pouch is too tight, it can constrict blood flow and cause injury. Rubbing the peristomal skin dry (
A) can cause irritation, applying the pouch while the skin is damp (
B) can lead to poor adhesion, and changing the pouch every 24 hours (
C) is unnecessary unless leakage or skin irritation occurs.
Question 5 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: A
Rationale: The correct answer is A: Check the blood product's compatibility with the client's blood type. This is crucial to prevent a potentially life-threatening transfusion reaction. The nurse must verify that the blood product matches the client's blood type to avoid hemolysis. Checking for compatibility ensures that the client's immune system will not attack the transfused blood cells.
Choices B, C, and D are incorrect:
B: Checking for a small gauge IV catheter is important for administering blood products, but it is not the priority before the start of the infusion.
C: Confirming the client's identity with the blood bank technician is essential but does not directly relate to the safety of the transfusion.
D: Priming the IV tubing with lactated Ringer's is not necessary as the packed RBCs should be administered with a separate tubing set to prevent any potential interactions.