ATI RN
ATI RN Fundamentals 2023 II Questions
Extract:
Question 1 of 5
A nurse is teaching a client how to self-administer heparin. Which of the following instructions should the nurse include in the teaching?
Correct Answer: C
Rationale:
Correct Answer: C - Expel air bubble before injecting medication.
Rationale:
1. Air bubbles can cause harm if injected into the bloodstream.
2. Expelling air ensures accurate dosage delivery.
3. Prevents air embolism, a potentially fatal complication.
4. Promotes safe and effective administration of heparin.
Summary:
A: Using an 18-gauge needle is too large and may cause discomfort.
B: Massaging the site can lead to bruising or discomfort.
D: Injecting 2 inches away from umbilicus is not a standard practice for heparin administration.
Question 2 of 5
A nurse is planning care for a client who is scheduled for an intravenous pyelogram. Which of the following actions is appropriate for the nurse to include?
Correct Answer: C
Rationale: The correct answer is C: Assist the client with a bowel cleansing. Prior to an intravenous pyelogram, it is important to ensure the client has a clear bowel to improve visualization of the urinary tract. This is typically achieved through bowel cleansing to prevent any fecal material from obstructing the view of the kidneys and bladder during the procedure.
Incorrect choices:
A: Ensuring the client is free of metal objects is important for MRI scans, not intravenous pyelograms.
B: Monitoring for pain in the suprapubic region is not a standard preparation for an intravenous pyelogram.
D: Administering oral contrast is not typically required for an intravenous pyelogram, as the contrast material is injected intravenously for this procedure.
Question 3 of 5
A nurse is preparing to set up a sterile field. Which of the following actions should the nurse take?
Correct Answer: C
Rationale: The correct answer is C: Hold bottles of sterile solution with the label in the palm of the hand. This is important to maintain sterility as the label may come into contact with non-sterile surfaces. Holding the bottle this way prevents contamination. Pouring liquids into containers outside the sterile field (
A) can introduce contaminants. Placing the sterile field at the level of the nurse's hips (
B) may lead to contamination from non-sterile surfaces. Opening the outermost flap of the sterile kit toward the body (
D) risks contamination as well. Placing the client in high-Fowler's position (E) is unrelated to setting up a sterile field.
Question 4 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: D
Rationale: The correct answer is D because using a straw to drink thickened juice can be dangerous for a client with dysphagia. Straws can increase the risk of aspiration as they bypass the natural protection mechanisms in the mouth and throat. The other choices are incorrect because:
A) taking frequent breaks while eating is actually a good strategy for someone with dysphagia to prevent choking,
B) adjusting the head of the bed to 90° helps with swallowing, and
C) tucking the chin when swallowing can help protect the airway.
Question 5 of 5
A nurse in an emergency department is assessing a client who reports right lower quadrant pain, nausea, and vomiting for the past 48 hr. Which of the following actions should the nurse take first?
Correct Answer: D
Rationale: The correct answer is D: Auscultate bowel sounds. This is the first action the nurse should take to assess for signs of bowel obstruction, a potential emergency with the client's symptoms. Absence of bowel sounds may indicate a blockage and prompt further intervention. Offering pain medication (
A) without assessing the underlying cause could mask symptoms. Palpating the abdomen (
B) could potentially worsen a blockage if present. Administering an antiemetic (
C) may help with nausea but does not address the root cause.