ATI RN
ATI N103N103 Fundamentals Final Exam Questions
Extract:
Question 1 of 5
A nurse is rounding on a client with bilateral wrist restraints. Which finding would warrant the nurse to loosen the restraints?
Correct Answer: C
Rationale: Cyanotic digits indicate impaired circulation necessitating immediate loosening to prevent tissue damage. Full range of motion (
A) and no discomfort (
D) suggest adequate restraint fit while attempting to remove them (
B) requires monitoring not loosening.
Question 2 of 5
A nurse is rounding on a client with bilateral wrist restraints. Which finding would warrant the nurse to loosen the restraints?
Correct Answer: C
Rationale: Cyanotic digits indicate impaired circulation necessitating immediate loosening to prevent tissue damage. Full range of motion (
A) and no discomfort (
D) suggest adequate restraint fit while attempting to remove them (
B) requires monitoring not loosening.
Question 3 of 5
A nurse is providing an in-service about repositioning clients and the use of lift pads for immobile clients. What is the rationale for placing lift pads under an immobile client?
Correct Answer: C
Rationale: Lift pads reduce friction/shearing during repositioning preventing skin damage. Staff injury prevention (
A) incontinence management (
B) and diaphoresis (
D) are not primary purposes.
Question 4 of 5
A nurse is assessing a client who is 2 days postoperative and is auscultating their bilateral breath sounds. The nurse notes absent breath sounds in the bases. The nurse should suspect which postoperative complication is occurring in this client?
Correct Answer: A
Rationale: Absent breath sounds in the lung bases post-surgery suggest atelectasis, where alveoli collapse due to shallow breathing or immobility. Pulmonary embolism, arterial thrombus, or pneumonia typically present with other signs like crackles or systemic symptoms.
Question 5 of 5
A nurse is caring for a client who is immobile. Which prophylactic intervention would be used to prevent complications of immobility?
Correct Answer: A
Rationale: Compression stockings prevent deep vein thrombosis by improving leg circulation, a key complication of immobility. Side rails address falls, catheters risk infections, and friction devices prevent ulcers but are less comprehensive.