ATI RN
RN-ATI-Fundamentals-of-Nursing-2023-2024 Questions
Extract:
Question 1 of 5
A nurse is receiving change-of-shift report for a group of clients. Which of the following clients should the nurse plan to assess first?
Correct Answer: B
Rationale: The correct answer is B. The nurse should assess the client with a hip fracture and new onset of tachypnea first because tachypnea could indicate a potentially life-threatening condition such as a pulmonary embolism or hypoxia. Assessing this client first ensures prompt detection and intervention for any respiratory compromise. Clients with epidural analgesia and weakness in lower extremities (
A) may need assessment for neurovascular compromise but are not in immediate danger. Clients with sinus arrhythmia (
C) on cardiac monitoring and diabetes mellitus with HbA1C of 6.8% (
D) require monitoring and management but do not present an immediate threat to their health.
Extract:
Laboratory Results 1200: Hgb 9.5 g/dL (14 to 18 g/dL)
Hct 38% (42% to 52%) Bilrubin 5.3 mg/dl (0.3 to 1.0 mg/dL) [ instruct the client to avoid blowing their nose forcefully.
Creatinine 1.8 mg/dL (0.6 to 1.3 mg/dL) [ Assess the dlent’s level of oientation
Platelet count 100,000/mm? (150,000 to 400,000/mm?)
[ Place the client under contact isolation.
1800:
Alanine aminotransferase ALT 51 units/L (4 to 36 units/L) Aspartate aminotransferase AST 48 units/L (0 to 35 units/L)
Alkaline phosphate ALP 151 units/L (30 to 120 units/L) Blood total protein 15 g/dL (6.4 to 8.3 g/dL
Question 2 of 5
A nurse is caring for a client who has been admitted to the hospital. Select the 5 actions the nurse should take?
Correct Answer: A,B,C,E,F
Rationale:
Correct Answer: A,B,C,E,F
Rationale:
A: Providing frequent rest periods aids in the client's recovery and prevents fatigue.
B: Restricting sodium intake is crucial for clients with certain conditions like hypertension.
C: Avoiding soap and alcohol-based lotions can prevent skin irritation, especially for sensitive skin.
E: Blowing nose forcefully can cause ear issues, so advising against it is essential.
F: Assessing orientation helps monitor the client's cognitive status and detect any changes early.
Summary:
D: There is no indication in the scenario to place the client on a low-carbohydrate diet.
G: Option G is missing, so it cannot be considered as a valid action in this context.
Extract:
Question 3 of 5
A nurse is reinforcing teaching about advance directives with a client who has end-stage renal disease. Which of the following client statements indicates an understanding of the teaching?
Correct Answer: A
Rationale: The correct answer is A: "I know that I can change my advance directives if needed in the future." This statement indicates an understanding of advance directives, which are legal documents that allow individuals to specify their healthcare preferences. Being able to change the directives reflects the client's awareness of the flexibility and control they have over their healthcare decisions.
Explanation for why other choices are incorrect:
B: "My healthcare proxy will make decisions as soon as I sign the power of attorney." This is incorrect because a healthcare proxy only makes decisions when the individual is unable to do so themselves.
C: "My family can overrule the decisions made by my healthcare proxy." This is incorrect because the healthcare proxy's decisions should be respected and followed.
D: "Advance directives from one state are valid in any other state." This is incorrect as advance directives must comply with the laws of the state they are in.
Question 4 of 5
A nurse is caring for a client who requires nasotracheal suctioning. Identify the sequence the nurse should follow to perform suctioning.
Correct Answer: D,C,B,E,A
Rationale:
To properly perform nasotracheal suctioning, the nurse should first don sterile gloves to maintain aseptic technique (
D).
Then, the nurse should turn on the suction and set the pressure (
C) to the appropriate level. Next, insert the catheter during the client's expiration, not inspiration, to minimize the risk of aspiration (
B). Apply suction while carefully rotating the catheter to remove secretions effectively (E). Finally, rinse the catheter to ensure it is clear of any remaining secretions (
A). This sequence ensures the safety and effectiveness of the suctioning procedure by following proper infection control measures and maintaining patient comfort.
Question 5 of 5
A nurse is providing discharge teaching to the partner of a client who has a tracheostomy. Which of the following information should the nurse include in the teaching?
Correct Answer: A
Rationale: The correct answer is A: How to operate the portable suction machine. This is important because maintaining a patent airway is crucial for a client with a tracheostomy. Suctioning helps to remove secretions and prevent blockages. Teaching the partner how to operate the suction machine ensures that they can assist in emergencies and daily care.
Choice B (How to secure the tracheostomy tube with ties at the back of the neck) is incorrect because securing the tube is important, but it is typically done by healthcare professionals initially and may not need to be done daily by the partner.
Choice C (How to change the nondisposable tracheostomy tube daily) is incorrect because changing the tracheostomy tube is a sterile procedure that should be done by healthcare professionals, not the partner.
Choice D (How to change the tracheostomy dressing using clean technique) is incorrect because changing the dressing is also typically done by healthcare professionals and requires sterile technique, not just