ATI RN
RN-ATI-Fundamentals-of-Nursing-2023-2024 Questions
Extract:
Question 1 of 5
A nurse is reinforcing teaching with a client who has hypertension and a prescription to measure her blood pressure daily. Which of the following client statements indicates an understanding of the teaching?
Correct Answer: C
Rationale:
Correct Answer: C. "I should remove constrictive clothing prior to measuring my blood pressure."
Rationale: Removing constrictive clothing ensures accurate blood pressure readings by preventing interference with blood flow. Tight clothing can artificially elevate blood pressure readings. By removing constrictive clothing, the client allows for an accurate assessment of their blood pressure.
Choice A: Waiting 15 minutes after drinking coffee is not directly related to obtaining an accurate blood pressure reading. Caffeine intake can temporarily raise blood pressure, but waiting 15 minutes may not be sufficient to eliminate its effects.
Choice B: Measuring blood pressure with the arm elevated above the heart is not a recommended method for accurate readings. The arm should be supported at heart level for accurate measurements.
Choice D: Measuring blood pressure immediately after eating breakfast can lead to inaccurate readings. It is recommended to wait at least 30 minutes after consuming a meal before measuring blood pressure for accurate results.
Question 2 of 5
A nurse is caring for a client who has given informed consent for electroconvulsive therapy. Just before the procedure, the client tells the nurse she is considering not going forward with the treatment. Which of the following statements by the nurse is appropriate?
Correct Answer: D
Rationale: The correct answer is D: "You don't have to go through with the treatment." This response respects the client's right to change their mind even after giving initial consent. It upholds the principle of autonomy and informed decision-making in healthcare.
Choices A and B do not acknowledge the client's right to withdraw consent and could potentially pressure the client.
Choice C, while empathetic, does not address the client's statement directly. Summarily, choices A, B, and C do not prioritize the client's autonomy and respect for their decision-making.
Question 3 of 5
A nurse is assessing a client who has preeclampsia and is receiving magnesium sulfate via continuous IV infusion. For which of the following therapeutic effects should the nurse monitor the client?
Correct Answer: A
Rationale: The correct answer is A: Deep tendon reflexes 2+. In clients receiving magnesium sulfate for preeclampsia, monitoring deep tendon reflexes is crucial as magnesium sulfate can lead to muscle weakness and decreased reflexes, indicating potential toxicity. Monitoring for 2+ reflexes ensures the client is within the therapeutic range. Pulse rate (
B) and urine output (
C) are important to monitor but are not specific therapeutic effects of magnesium sulfate. Proteinuria (
D) is a sign of preeclampsia and not a therapeutic effect of the medication.
Question 4 of 5
A nurse is reinforcing teaching with a client who has hypertension and a prescription to measure her blood pressure daily. Which of the following client statements indicates an understanding of the teaching?
Correct Answer: C
Rationale:
Correct Answer: C. "I should remove constrictive clothing prior to measuring my blood pressure."
Rationale: Removing constrictive clothing ensures accurate blood pressure readings by preventing interference with blood flow. Tight clothing can artificially elevate blood pressure readings. By removing constrictive clothing, the client allows for an accurate assessment of their blood pressure.
Choice A: Waiting 15 minutes after drinking coffee is not directly related to obtaining an accurate blood pressure reading. Caffeine intake can temporarily raise blood pressure, but waiting 15 minutes may not be sufficient to eliminate its effects.
Choice B: Measuring blood pressure with the arm elevated above the heart is not a recommended method for accurate readings. The arm should be supported at heart level for accurate measurements.
Choice D: Measuring blood pressure immediately after eating breakfast can lead to inaccurate readings. It is recommended to wait at least 30 minutes after consuming a meal before measuring blood pressure for accurate results.
Question 5 of 5
A nurse is setting up a sterile field to perform wound irrigation for a client. Which of the following actions should the nurse take when pouring the sterile solution?
Correct Answer: A
Rationale: The correct answer is A. When setting up a sterile field for wound irrigation, the nurse should remove the cap of the sterile solution bottle and place it sterile-side up on a clean surface. This is crucial to maintain the sterility of the solution. Placing the cap sterile-side up prevents contamination from the surface.
Choices B and C are incorrect as they do not address the proper handling of the solution bottle.
Choice D is incorrect as holding the bottle with the label facing away from the palm does not ensure the sterility of the solution. It is essential to follow proper aseptic technique to prevent infection and promote healing.