ATI RN
ATI Nurs100102 Fundamentals Retake Questions
Extract:
Question 1 of 5
A nurse is teaching a client who reports insomnia about promoting rest and sleep. Which of the following statements should the nurse identify as an indication that the client understands the instructions?
Correct Answer: D
Rationale: The correct answer is D: "I will no longer have a glass of wine before bedtime." This is correct because alcohol consumption can disrupt sleep patterns and worsen insomnia. By avoiding alcohol before bedtime, the client is implementing a behavior change that promotes better sleep hygiene.
A: Having hot cocoa before bedtime can actually interfere with sleep due to its caffeine content.
B: Brisk physical activity close to bedtime can increase alertness and make it harder to fall asleep.
C: Muscle relaxation techniques in the afternoon may not directly address the issue of alcohol consumption affecting sleep.
E, F, G: These choices are not relevant to addressing insomnia specifically.
Question 2 of 5
A nurse is preparing to assist a client who can partially bear weight and is cooperative with transfer from the bed to a chair. Which of the following actions should the nurse take to maintain safety during the transfer?
Correct Answer: C
Rationale: The correct answer is C: Use a powered standing-assist lift. This option is the safest choice as it minimizes the risk of injury during the transfer process. The powered standing-assist lift provides support and stability, making the transfer easier for both the nurse and the client. It reduces the strain on the nurse's back and decreases the likelihood of falls or accidents. Enlisting help from another staff member (
A) may not provide sufficient support or stability. Avoiding movements that twist the spine (
B) is important but may not be enough to ensure safety during the transfer. Adjusting the bed to an appropriate height (
D) is helpful but does not address the need for proper support and stability during the transfer.
Question 3 of 5
A nurse is caring for a client who has had an allogeneic hematopoietic stem-cell transplant. Which of the following infection-control precautions should the nurse use while caring for this client?
Correct Answer: C
Rationale: The correct answer is C: Neutropenic precautions. Patients with allogeneic hematopoietic stem-cell transplants have compromised immune systems, specifically low neutrophil counts, putting them at high risk for infections. Neutropenic precautions aim to reduce exposure to pathogens, including strict hand hygiene, limiting visitors, and avoiding fresh fruits and flowers. Contact precautions (
A) are used for diseases spread by direct contact, airborne precautions (
B) for diseases spread by tiny droplets in the air, and droplet precautions (
D) for diseases spread by large respiratory droplets. Neutropenic precautions are the most appropriate for this client due to their immunocompromised state.
Question 4 of 5
A nurse is teaching an older adult client who has left-sided weakness about cane use. Which of the following instructions should the nurse include?
Correct Answer: A
Rationale: The correct answer is A: When walking, move your left foot forward first. This instruction is important because the client has left-sided weakness, so moving the left foot first helps provide support and stability on the weaker side. This ensures proper weight distribution and reduces the risk of falls. Option B is incorrect because keeping the elbow straight can lead to discomfort and poor control. Option C is incorrect as moving the cane too far ahead can cause imbalance. Option D is incorrect as the cane should be held on the stronger side for better support.
Question 5 of 5
A nurse is caring for a client who sustained blood loss. Which of the following is a manifestation of hypovolemia?
Correct Answer: C
Rationale: The correct answer is C: Weak pulse. Hypovolemia, or low blood volume, results in a decrease in circulating blood volume leading to a weak pulse. This occurs because there is less blood volume to generate adequate pressure against the arterial walls. Decreased heart rate (
A) is not a typical manifestation of hypovolemia as the body usually compensates by increasing heart rate to maintain cardiac output. Increased blood pressure (
B) is also not characteristic of hypovolemia, as blood pressure tends to decrease due to decreased blood volume. Dyspnea (
D) may occur in severe cases of hypovolemia due to inadequate oxygen delivery, but it is not a primary manifestation.