ATI RN
ATI RN Fundamentals 2023 Exam 5 Questions
Extract:
Question 1 of 5
A nurse is teaching a client about logrolling while in bed. Which of the following information should the nurse include in the teaching?
Correct Answer: D
Rationale: Friction prevention is a benefit but not the primary purpose. Arms should be crossed over the chest, not at the sides. The bed should be flat, not elevated. Logrolling maintains spinal alignment, critical for clients with spinal issues.
Question 2 of 5
A nurse is providing information to a client about durable power of attorney. The nurse should include that durable power of attorney is enforceable under which of the following conditions?
Correct Answer: C
Rationale: Self-care incapacity or terminal illness doesn’t automatically trigger it; it’s enforceable when the client can’t express wishes due to incapacity. Refusal of treatment doesn’t activate it if the client is competent.
Question 3 of 5
A nurse is caring for a client who has dysphagia. When assisting the client during breakfast, which of the following actions by the client indicates the nurse should intervene?
Correct Answer: B
Rationale: Adjusting the head of the bed to 90° is a recommended practice for clients with dysphagia. This position helps facilitate swallowing and reduces the risk of aspiration by using gravity to assist the passage of food and liquids from the mouth to the stomach. Drinking thickened juice with a straw is not recommended for clients with dysphagia. Using a straw can increase the speed and force with which liquids enter the mouth, making it harder to control the swallow and increasing the risk of aspiration. Thickened liquids are designed to move more slowly, giving the client more control over swallowing, but using a straw negates this benefit. Taking frequent breaks while eating is a good practice for clients with dysphagia. It allows them to chew and swallow food thoroughly, reducing the risk of choking and aspiration. This practice also helps prevent fatigue, which can impair swallowing function. Tucking the chin when swallowing, also known as the chin-tuck maneuver, is a common technique used to help clients with dysphagia. This action helps protect the airway by narrowing the space and reducing the risk of aspiration.
Question 4 of 5
A nurse is assessing a client who received morphine for severe pain 30 minutes ago. Which of the following findings is the nurse's priority?
Correct Answer: B
Rationale: While it is important to monitor bowel movements, especially since opioids like morphine can cause constipation, this is not the immediate priority. Opioid-induced constipation is a common side effect due to decreased gastrointestinal motility. However, it does not pose an immediate life-threatening risk compared to respiratory depression. A respiratory rate of 7 breaths per minute is significantly below the normal range for adults, which is typically 12-20 breaths per minute. This indicates severe respiratory depression, a known and potentially fatal side effect of morphine. Immediate intervention is required to ensure the patient's airway is maintained and to prevent respiratory arrest. Although the client reporting a pain level of 8 out of 10 indicates that the pain is not adequately controlled, this is not the most urgent concern compared to respiratory depression. Pain management is crucial, but ensuring the patient's respiratory function takes precedence. A distended bladder can be a side effect of morphine due to urinary retention. While this needs to be addressed to prevent discomfort and potential complications, it is not as critical as managing a severely low respiratory rate.
Question 5 of 5
A nurse is administering multiple types of ophthalmic drops to a client. Which of the following actions should the nurse take?
Correct Answer: A
Rationale: Waiting 5 minutes between the administration of each medication is the most appropriate action. This allows each medication to be absorbed properly without being washed away by the subsequent drops. Adequate absorption ensures that each medication can exert its therapeutic effect effectively. Asking the client to close their eyes tightly after instilling each medication is not recommended. This action can force the medication out of the eye, reducing its effectiveness. Instead, clients should be advised to close their eyes gently to allow the medication to spread evenly across the eye surface. Holding the dropper 3 cm (1.2 in) away from the client's eye is too far. The recommended distance is about 1 to 2 cm (0.4 to 0.8 in) to ensure that the drops are accurately placed in the conjunctival sac without touching the eye or eyelashes, which could cause contamination. Massaging the client's eyelids for 20 seconds after instillation is not a standard practice for administering ophthalmic drops. This action could potentially irritate the eye or cause discomfort. Instead, gentle pressure can be applied to the inner corner of the eye (nasolacrimal duct) for a few seconds to prevent the medication from draining into the tear duct.