ATI RN
ATI Nur 231 Fundamentals Exam Questions
Extract:
Question 1 of 5
A nurse is presenting to a class about fall prevention to a group of assisted-living residents. Which of the following statements by a resident best indicates an understanding of the teaching?
Correct Answer: D
Rationale: It is a good idea to use the handrails in the bathroom: Handrails provide stability and support when navigating potentially slippery areas, such as bathrooms, and can significantly reduce the risk of falls.
Question 2 of 5
A nurse is caring for a client who experienced an infection at the insertion site of her intravenous catheter. Which of the following findings should the nurse expect?
Correct Answer: B
Rationale: Purulent drainage is noted from the site: The presence of purulent drainage is a clear sign of infection. Purulent drainage typically indicates the accumulation of pus, which is a result of the body's immune response to infection.
Question 3 of 5
The nurse is notifying the HCP of the client's change in status using the SBAR format. In which order should the nurse place the statements? 1. 'I suggest that the client be transferred to the critical care unit, and I would like you to come evaluate the client.' 2. 'The client is deteriorating, and I'm afraid the client is going to arrest.' 3. 'I am calling about (client name and location). Vital signs are BP=100/50, P=120, RR=30, T=100.4°F (38°C).' 4. 'The client is becoming confused and agitated. The skin is pale, mottled, and diaphoretic. The client is very dyspneic with an oxygen saturation of 85% despite placing a nonrebreather mask.'
Correct Answer: A
Rationale: In SBAR format, the order is: Situation (2), Background (4), Assessment (3), and Recommendation (1). This statement provides a clear and urgent indication of the client's current status, emphasizing the severity of the situation and the immediate concern for potential cardiac arrest. The nurse’s choice of language conveys a sense of urgency that is crucial for the HCP to understand the need for prompt action.
Question 4 of 5
A nurse is planning care for a hospitalized client who is immobile and in a continuous mitten restraint. Which of the following interventions should be included in the client's care plan? (Select all that apply.)
Correct Answer: A,B,C,D
Rationale: Obtain the provider's prescription renewal every 72 hr.: This is an essential intervention. Document restraint checks and client status every 2 hr.: Regular documentation is vital. Implement passive range-of-motion exercises: Important for preventing joint stiffness. Educate the client's family about restraint use: Provides transparency and support.
Question 5 of 5
The patient has a risk for skin impairment and has a 15 on the Braden Scale upon admission. The nurse has implemented interventions. Upon reassessment, which Braden score will be the best sign that the risk for skin breakdown is removed?
Correct Answer: A
Rationale: 18: A score of 18 on the Braden Scale indicates that the patient is at low risk for skin breakdown. A score of 18 or above suggests that the implemented interventions have effectively reduced the risk of skin impairment.