ATI RN
ATI RN Fundamentals 2023 I Questions
Extract:
Question 1 of 5
A nurse is teaching a client about reducing the risk for osteoporosis. Which of the following statements by the client indicates an understanding of possible anaphylaxis?
Correct Answer: D
Rationale: The correct answer is D: A sharp decrease in blood pressure. This indicates an understanding of possible anaphylaxis because anaphylaxis is a severe allergic reaction that can lead to a sudden drop in blood pressure, which can be life-threatening. This symptom is crucial to recognize as it requires immediate medical attention, including the administration of epinephrine.
Choice A, B, and C do not directly relate to anaphylaxis and are more commonly associated with other conditions or reactions. By understanding the potential signs of anaphylaxis, the client can take appropriate actions to seek help promptly.
Question 2 of 5
A nurse is teaching a client who has decreased mobility about passive range-of-motion exercises. Which of the following statements should the nurse make?
Correct Answer: B
Rationale: The correct answer is B: "I will repeat these movements 3 to 5 times." This is the appropriate statement because passive range-of-motion exercises should be repeated multiple times to prevent joint stiffness and contractures. Repeating the movements helps maintain joint flexibility and circulation.
Explanation of why the other choices are incorrect:
A: "I will move your joints to the point of mild pain" - Incorrect because pain should be avoided during passive range-of-motion exercises to prevent injury and discomfort.
C: "I will move your joints quickly" - Incorrect because slow, controlled movements are recommended to prevent injury and ensure effectiveness.
D: "These movements will be performed once per day" - Incorrect because passive range-of-motion exercises are usually performed multiple times throughout the day to promote joint mobility and prevent stiffness.
Question 3 of 5
A community health nurse is visiting an older adult client who recently moved into an assisted living apartment. Which of the following client statements indicates difficulty accepting their transition?
Correct Answer: B
Rationale:
Correct Answer: B
Rationale:
Choice B indicates difficulty accepting the transition as the client is isolating themselves from social activities due to perceived differences with other residents. This can lead to feelings of loneliness and reluctance to engage with the new community. In contrast, choices A, C, and D show the client adapting positively to the new environment by acknowledging benefits, following staff advice for safety, and finding alternative transportation solutions.
Summary:
Choice B stands out as the client's statement reflects potential social withdrawal, while the other choices demonstrate acceptance and adaptation to the changes in the assisted living setting.
Question 4 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 5 of 5
A nurse is caring for a client who is immobile. Which of the following interventions should the nurse plan to take to prevent plantar flexion contractures?
Correct Answer: B
Rationale: The correct answer is B: Use foot splints. Foot splints help maintain the foot in a neutral position, preventing plantar flexion contractures. Trochanter roll (
A) is used to maintain hip abduction. Applying an abduction pillow (
C) is helpful for hip alignment. Propping the feet up (
D) does not prevent plantar flexion contractures.