ATI RN
ATI RN Fundamentals 2023 II Questions
Extract:
Question 1 of 5
A nurse is providing teaching to a client about reducing the adverse effects of immobility. Which of the following statements by the client indicates an understanding of the teaching?
Correct Answer: D
Rationale: The correct answer is D because performing ankle and knee exercises every hour helps improve circulation and prevent complications like blood clots associated with immobility. Holding breath (choice
A) is incorrect as it can cause dizziness. Having a partner help change positions every 4 hours (choice
B) is incorrect because changing positions every 2 hours is recommended. Removing antiembolic stockings while in bed (choice
C) is incorrect as they should be worn when in bed. In summary, the other choices are incorrect as they do not address the specific issue of reducing adverse effects of immobility.
Question 2 of 5
A home health nurse is teaching a client about home safety. Which of the following statements by the client indicates an understanding of the teaching? (Select all that apply.)
Correct Answer: B,C,D
Rationale:
Correct Answer: B, C, D
Rationale:
B: Using grab bars in the bathtub promotes safety by preventing slips and falls, especially for individuals with mobility issues.
C: Having a fire escape plan is crucial for preparedness in case of emergencies, ensuring the client's and their family's safety.
D: Checking medication expiration dates is essential to prevent using expired medications, which can lead to ineffective treatment or harm.
Incorrect
Choices:
A: Applying tape over frayed electrical cords is unsafe as it can increase the risk of electrical fires and shocks.
E: No information is provided to assess the correctness of this statement.
F: No information is provided to assess the correctness of this statement.
G: No information is provided to assess the correctness of this statement.
Question 3 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 4 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.
Question 5 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: C
Rationale: The correct answer is C: Provide the client with a night light. This is important for fall prevention as it helps the client see the surroundings during the night, reducing the risk of tripping or falling. A: Keeping the room temperature low can increase the risk of falls due to discomfort. B: Placing the table far from the bed can make it difficult for the client to reach items and increase the risk of falls. D: Elevating full-length side rails can lead to entrapment and should only be used when necessary and with proper assessment.