ATI RN
ATI RN Fundamentals Updated 2023 Exam Questions
Extract:
Question 1 of 5
A nurse is teaching a group of newly licensed nurses about the Braden scale. Which of the following responses by a newly licensed nurse indicates an understanding of the teaching?
Correct Answer: B
Rationale:
Correct
Answer: B - The scale measures six elements.
Rationale: The Braden scale is used to assess a patient's risk for developing pressure ulcers and consists of six elements: sensory perception, moisture, activity, mobility, nutrition, and friction/shear. Understanding this indicates knowledge of the scale's components.
Incorrect
Choices:
A: Each element has a range from one to five points - This is incorrect because the elements are not scored on a range from one to five.
C: The client's age is part of the measurement - Age is not a factor in the Braden scale assessment.
D: The higher the score, the higher the pressure injury risk - This is incorrect as a higher score on the Braden scale indicates a lower risk of pressure ulcers.
Question 2 of 5
A nurse is planning care for a client who has a new prescription for parenteral nutrition (PN) in 20% dextrose and fat emulsions. Which of the following is an appropriate action to include in the plan of care?
Correct Answer: A
Rationale:
Correct
Answer: A - Prepare the client for a central venous line.
Rationale: Parenteral nutrition with high dextrose concentration can cause phlebitis and vein irritation if administered through peripheral IV. A central venous line allows for the hypertonic solution to be infused safely into a larger vein, reducing the risk of complications.
Summary of other choices:
B: Changing the PN infusion bag every 48 hr is a standard practice, but it is not directly related to the type of solution being infused.
C: Obtaining a random blood glucose daily is important for monitoring, but it does not address the specific safety issue related to administering high dextrose concentration.
D: Administering the PN and fat emulsion separately may be necessary for compatibility reasons, but it does not address the safety concern of using a central venous line for the 20% dextrose solution.
Question 3 of 5
A nurse is teaching a group of newly licensed nurses about the Braden scale. Which of the following responses by a newly licensed nurse indicates an understanding of the teaching?
Correct Answer: B
Rationale: The correct answer is B because the Braden scale measures six elements: sensory perception, moisture, activity, mobility, nutrition, and friction/shear. Each element is rated on a scale from 1 to 4, except for friction/shear, which is rated from 1 to 3. Understanding this key aspect of the Braden scale demonstrates a comprehensive knowledge of the tool.
Choice A is incorrect because each element is rated on a scale from 1 to 4 or 1 to 3, not 1 to 5.
Choice C is incorrect because the client's age is not a factor in the Braden scale measurement.
Choice D is incorrect because the higher the score on the Braden scale, the lower the pressure injury risk, not higher.
Question 4 of 5
A nurse is caring for a client who has a tracheostomy. Which of the following actions should the nurse take?
Correct Answer: B
Rationale: The correct answer is B: Cleanse the skin around the stoma with normal saline. This is important to prevent infection and skin breakdown. Cleaning the skin helps maintain hygiene and prevents the build-up of secretions. Using normal saline is gentle and non-irritating to the skin.
A: Using a cotton tip applicator to clean inside the inner cannula can cause injury or dislodgment of the tracheostomy tube.
C: Soaking the outer cannula in warm, soapy tap water is not necessary for routine tracheostomy care and may introduce contaminants.
D: Securing the tracheostomy ties to allow one finger to fit snugly underneath is incorrect as it does not address the immediate need for skin cleansing.
Question 5 of 5
A nurse is conducting the Weber's test on a client. Which of the following is an appropriate action for the Weber's test?
Correct Answer: C
Rationale: The correct action for the Weber's test is to place an activated tuning fork in the middle of the client's forehead. This is done to assess for lateralization of sound in cases of unilateral hearing loss. When the tuning fork is placed on the forehead, the sound is conducted through bone conduction to both ears equally. In a normal hearing individual, the sound should be heard equally in both ears. If the client has unilateral hearing loss, they will hear the sound louder in the better ear due to bone conduction. This helps to differentiate between conductive and sensorineural hearing loss. The other choices are incorrect as they do not pertain to the specific procedure of the Weber's test and do not provide the necessary information to assess for lateralization of sound.