ATI RN
ATI RN Fundamentals 2023 Exam 5 Questions
Extract:
Question 1 of 5
A nurse is teaching a client who can only bear weight on one leg how to ambulate using crutches. Which of the following crutch gaits should the nurse plan to instruct the client to use?
Correct Answer: C
Rationale: The four-point alternating gait is used when a client can bear weight on both legs. This gait provides maximum stability and is often used for clients with poor balance or coordination. It involves moving one crutch forward, followed by the opposite leg, then the other crutch, and finally the other leg. Since the client can only bear weight on one leg, this gait is not appropriate. The two-point alternating gait is also used when a client can bear weight on both legs. It is faster than the four-point gait and involves moving one crutch and the opposite leg simultaneously, followed by the other crutch and the opposite leg. This gait requires partial weight-bearing on both legs, making it unsuitable for a client who can only bear weight on one leg. The three-point gait is specifically designed for clients who can only bear weight on one leg. In this gait, both crutches are moved forward together, followed by the weight-bearing leg. The non-weight-bearing leg is then swung through. This gait provides the necessary support and stability for clients with one non-weight-bearing leg, making it the most appropriate choice in this scenario. The swing-through gait is used by clients who have good upper body strength and can bear weight on both legs, even if one leg is weaker. This gait involves moving both crutches forward together and then swinging both legs through to the crutches. It is not suitable for a client who can only bear weight on one leg, as it requires some degree of weight-bearing on both legs.
Question 2 of 5
A nurse is considering placing wrist restraints on a client who has cognitive deficits and has pulled out their IV catheter. Before using wrist restraints, which of the following actions must the nurse take first?
Correct Answer: D
Rationale: Documenting the indications for using wrist restraints is an important step in the process, but it is not the first action the nurse should take. Documentation ensures that there is a clear rationale for the use of restraints and helps in maintaining legal and ethical standards. However, before documenting, the nurse must explore and attempt less restrictive alternatives to ensure that restraints are truly necessary. Obtaining a prescription for restraints from the provider is a crucial step, as restraints should only be used with a valid order from a healthcare provider. This ensures that the use of restraints is medically justified and that the provider is aware of the client's condition. However, before seeking a prescription, the nurse must first attempt less restrictive alternatives to manage the client's behavior. Explaining the procedure to the client and their family is an important step in obtaining informed consent and maintaining transparency. However, it should be done after the nurse has determined that less restrictive alternatives are not effective and that restraints are necessary. Attempting less restrictive alternatives is the first action the nurse must take. This approach aligns with ethical and legal guidelines that emphasize the use of the least restrictive measures to ensure the client's safety. Alternatives may include verbal de-escalation, environmental modifications, or the use of less restrictive devices. Only if these measures fail should the nurse consider using restraints.
Question 3 of 5
A nurse is teaching a client about stress management techniques. Which of the following client statements indicates an understanding of the teaching?
Correct Answer: B
Rationale: Inconsistent sleep disrupts stress management; support groups provide emotional relief; delegation reduces stress; and 1 hour/week exercise is insufficient (150 min/week recommended). Attending a support group reflects understanding.
Question 4 of 5
A nurse is providing discharge teaching to the partner of a client who has a linear incision site following an open cholecystectomy. Which of the following wound care instructions should the nurse include?
Correct Answer: C
Rationale: Changing the dressing four times per day is excessive and not typically recommended. Most guidelines suggest changing the dressing once a day or as needed if it becomes soiled or wet. Over-frequent dressing changes can disrupt the healing process and increase the risk of infection. Applying tincture of benzoin prior to removing the dressing is not a standard practice for wound care. Tincture of benzoin is usually used to increase the adhesion of bandages or tapes, not for removing dressings. Using it inappropriately could cause skin irritation or damage. Cleaning from the incision to the surrounding skin is the correct method. This technique helps prevent the spread of bacteria from the surrounding skin into the incision site, reducing the risk of infection. Always use a sterile solution and clean gauze for this process. Using sterile gloves when removing the old dressing is important to maintain a sterile environment and prevent infection. However, this is a general practice and not specific to the wound care instructions provided in the question.
Question 5 of 5
A nurse is assessing a client's abdomen. In what order should the nurse complete the steps of the assessment? (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)
Correct Answer: A,B,C,D,E
Rationale: Inspection (
A) comes first to observe visually, followed by auscultation (
B) to avoid altering bowel sounds, then percussion (
C) to assess underlying structures, light palpation (
D) to check tenderness, and deep palpation (E) to assess deeper structures like the aorta.