ATI RN
ATI RN Fundamentals 2023 I Questions
Extract:
Question 1 of 5
A nurse is reviewing the client’s medical record. Which of the following findings places the client at risk for heart disease? (Select all that apply.)
Correct Answer: A,B,C,E,F
Rationale: The correct answer includes family history, fasting glucose level, history of hyperlipidemia, hypertension, and cholesterol level. Family history is a non-modifiable risk factor for heart disease. Elevated fasting glucose indicates potential diabetes, a risk factor for heart disease. Hyperlipidemia contributes to plaque buildup in arteries. Hypertension strains the heart and blood vessels. Abnormal cholesterol levels can lead to atherosclerosis.
Choices D and G are not directly linked to heart disease risk.
Question 2 of 5
A nurse is reviewing the laboratory results of a female client who has liver dysfunction and is receiving a continuous tube feeding. Which of the following findings should the nurse identify as a protein deficiency?
Correct Answer: A
Rationale: The correct answer is A: Albumin 3.1 g/dL. Albumin is the main protein in the blood and is produced by the liver. In liver dysfunction, the synthesis of albumin is decreased, leading to low levels in the blood, indicating protein deficiency. Transferrin (
B) is a protein involved in iron transport, not a direct indicator of protein deficiency. Uric acid (
C) and total iron-binding capacity (
D) are not specific markers for protein deficiency.
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 cause pressure on the stoma leading to necrosis. If the pouch is too loose, leakage can occur. Applying the pouch while the skin barrier is still damp (choice
A) can lead to poor adhesion. Changing the pouch once every 24 hr (choice
B) may be too frequent and can irritate the skin. Rubbing the peristomal skin dry after cleaning (choice
C) can cause skin irritation.
Question 4 of 5
A nurse is preparing to administer a medication to a client for the first time. Which of the following actions should the nurse take to help ensure safe medication administration?
Correct Answer: A
Rationale: The correct answer is A: Read the medication label twice prior to administration. This is crucial to ensure that the right medication, dosage, and route are being administered to the correct patient. By double-checking the medication label, the nurse can verify that there are no errors or discrepancies that could lead to medication errors. Using one patient identifier (
Choice
B) is important but not specific to medication safety. Accessing the online drug formulary (
Choice
C) is helpful for additional information but not essential for immediate safe administration. Asking the client about previous medication history (
Choice
D) is relevant but does not guarantee safe administration as it relies on the client's memory and may not always be accurate.
Question 5 of 5
A nurse is planning care for a client who has a prescription for extremity restraints to both wrists. Which of the following actions should the nurse include in the plan of care? (Select all that apply.)
Correct Answer: A,B,D
Rationale:
Correct Answer: A, B, D
Rationale:
A: Ensuring the client’s bed is in the lowest position prevents falls and minimizes injury risk if the client tries to get out of bed.
B: Assessing skin temperature and color before applying restraints ensures proper circulation and skin integrity.
D: Padding bony prominences before applying restraints prevents pressure ulcers and discomfort for the client.
Summary:
C: Attaching the restraints to the bed rail can increase the risk of injury if the client moves around.
E: Allowing three fingers to slide under the restraints is incorrect as it can lead to improper fit and ineffective restraint.