ATI RN
ATI Fundamentals 2023 Retake 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: B
Rationale: The correct answer is B: Roll the client as one unit in a smooth, continuous motion. This is the safest method to reposition a client with a lower back injury because it minimizes strain on the back and reduces the risk of injury. Rolling the client as one unit maintains the alignment of the spine and prevents unnecessary twisting or bending. Flexing the client's knees (choice
A) may be uncomfortable or cause further strain on the lower back. Placing the client on the side of the bed nearest the direction they will be turned (choice
C) is not as crucial as rolling the client as one unit. Placing the client's arms at their sides (choice
D) does not directly address the proper repositioning technique for a client with a lower back injury.
Question 2 of 5
A nurse is collecting a blood pressure (BP) reading from a client who is sitting in a chair. The nurse determines that the client's BP is 158/96 mm Hg. Which of the following actions should the nurse take?
Correct Answer: C
Rationale: The correct answer is C: Recheck the client's BP in her other arm for comparison. This is the best course of action because taking the BP in the other arm can help determine if the reading is accurate or if there is an issue with the equipment or technique. It is important to rule out any potential errors before taking further action.
Choice A is incorrect because waiting 30 minutes may not address the potential issue with the BP reading.
Choice B is incorrect because the width of the cuff should be appropriate for the arm size, not a specific percentage of the arm circumference.
Choice D is not necessary unless there are specific reasons to suspect positional effects on BP readings.
Question 3 of 5
A nurse is admitting a client who is at risk for falls to a medical-surgical unit. Which of the following actions should the nurse take?
Correct Answer: A
Rationale: The correct answer is A: Provide the client with a night light. This is important for fall prevention as it helps the client see clearly at night, reducing the risk of tripping or falling in the dark. Night lights can improve visibility and safety without disrupting sleep.
Choice B could potentially restrict the client's movement and increase the risk of entrapment.
Choice C does not directly address fall prevention.
Choice D focuses on room temperature, which is not directly related to fall risk.
Question 4 of 5
A nurse is teaching a client how to self-administer heparin. Which of the following instructions should the nurse include in the teaching?
Correct Answer: C
Rationale: The correct answer is C: Inject 5.1 cm (2 in) away from the umbilicus. This instruction is crucial as heparin injections should be administered subcutaneously at least 2 inches away from the umbilicus to prevent injury to internal organs. Option A is incorrect as heparin is typically administered using a smaller gauge needle, such as a 25-26 gauge. Option B is incorrect as massaging the injection site can lead to bruising or irritation. Option D is incorrect as expelling air bubbles before injecting medication is important to prevent air embolism, but it is not specific to heparin administration.
Question 5 of 5
A nurse is caring for a client who is postoperative following abdominal surgery. Which of the following findings should the nurse report to the provider first?
Correct Answer: B
Rationale: The correct answer is B: The client has a separation of their surgical incision. This finding should be reported first because it suggests a potential complication such as wound dehiscence, which can lead to serious consequences like infection or evisceration. Prompt intervention is necessary to prevent further complications.
A: The client's temperature of 38.3°C indicates a low-grade fever, which is concerning but not as urgent as a wound separation.
C: 3+ pitting edema in the lower extremities is indicative of fluid overload, which is important but not as immediately critical as a wound separation.
D: A urine output of 20 mL/hr is below the normal range, indicating possible renal impairment, but it is not as urgent as managing a wound separation.