ATI RN
ATI RN Fundamentals Updated 2023 Exam Questions
Extract:
Question 1 of 5
A nurse is teaching a client who is about to undergo a bowel resection about advance directives. Which of the following instructions should the nurse include in the teaching?
Correct Answer: C
Rationale: The correct answer is C: "You will receive written information about advance directives prior to signing." This instruction is important because it ensures that the client has the necessary information to make an informed decision about advance directives. Providing written information allows the client to fully understand the purpose and implications of advance directives before signing them.
Choice A is incorrect because the provider does not need to sign the advance directives, it is the client's decision.
Choice B is incorrect as the presence of a partner is not mandatory for signing advance directives.
Choice D is incorrect as signing advance directives is a personal choice and not a requirement before surgery.
Question 2 of 5
A nurse is preparing to perform a physical assessment of a client's abdomen. Identify the sequence in which the nurse should perform the following steps.
Correct Answer: A,B,C,E,D
Rationale: Action to Take: A, B; Potential Condition: C; Parameter to Monitor: D, E.
The correct sequence for performing a physical assessment of a client's abdomen involves the following steps:
1. Provide adequate lighting to inspect the abdomen (Action
A) to ensure clear visibility.
2. Listen to the abdominal arteries using the bell of a stethoscope (Action
B) to assess vascular sounds.
3. Percuss all four quadrants of the abdomen (Potential Condition
C) to measure sound quality and identify any abnormalities.
4. Check for areas of tenderness by pressing fingers 1.3 cm (0.5 in) into the abdomen (Parameter to Monitor E) to assess for pain or discomfort.
5. Locate liver and spleen borders by pressing hands 2.5 to 7.5 cm (1 to 3 in) into the abdomen (Parameter to Monitor
D) to assess organ size and position.
This sequence ensures a systematic and comprehensive assessment of the abdomen,
Question 3 of 5
A nurse is caring for a client who is 2 days postoperative following bowel resection and reports sudden, severe abdominal pain. Which of the following actions should the nurse take first?
Correct Answer: D
Rationale: The correct answer is D: Expose the client's abdomen to look for changes in appearance. This action should be taken first because sudden, severe abdominal pain postoperatively can indicate a serious complication like internal bleeding or bowel perforation. By exposing the abdomen, the nurse can visually assess for signs of distention, discoloration, or any other abnormality that may indicate a surgical complication. This visual assessment can provide crucial information to guide further interventions.
Choices A, B, and C involve assessment techniques that may be important in evaluating the client's condition, but they should be secondary to visually inspecting the abdomen in this urgent situation.
Choice A focuses on bowel sounds, which may not be reliable in a postoperative client experiencing sudden severe pain.
Choice B involves palpation, which could potentially exacerbate any existing complications.
Choice C refers to assessing areas of resonance, which is less urgent compared to visually inspecting for immediate changes in the abdomen.
In summary, visually inspecting the client's
Question 4 of 5
A nurse is caring for a client who has restraints to each extremity. Which of the following assessments should the nurse perform first?
Correct Answer: B
Rationale: The correct assessment the nurse should perform first is B: Peripheral pulses. Monitoring peripheral pulses is crucial when a client is restrained to detect any signs of compromised circulation. This assessment takes priority over the other options because impaired circulation can lead to serious complications such as tissue damage or even limb loss. Assessing skin integrity, comfort level, and elimination needs are important tasks but can wait until after ensuring adequate circulation. Checking peripheral pulses is the initial step to ensure the client's safety and prevent potential harm.
Question 5 of 5
A nurse is preparing to administer a controlled substance to a client for pain management. Which of the following actions should the nurse take?
Correct Answer: D
Rationale: The correct answer is D: Verify the count total of the controlled substance after removing the amount needed. This is crucial to ensure accurate documentation and prevent errors in medication administration. By verifying the count total after removing the needed amount, the nurse confirms that the correct dosage has been withdrawn and prevents any discrepancies in the controlled substance inventory.
Option A is incorrect because wasting the unused portion of the controlled substance should be witnessed by another nurse, not just the signature recorded. Option B is incorrect as reporting discrepancies in the count total should be done before administration, not after. Option C is incorrect as wasted portions of controlled substances should be disposed of according to facility policy, not necessarily in a sharps container.