ATI RN
ATI RN Fundamentals 2023 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: A
Rationale: The correct answer is A: "The scale measures six elements." The Braden scale indeed assesses six elements: sensory perception, moisture, activity, mobility, nutrition, and friction/shear. This response shows an understanding of the scale's components.
Choice B is incorrect because the client's age is not a factor in the Braden scale assessment.
Choice C is incorrect as a higher score on the Braden scale indicates a lower pressure injury risk.
Choice D is incorrect because each element on the Braden scale has a range from one to four points, not one to five.
Question 2 of 5
A nurse is caring for a client who has a colostomy. Which of the following actions should the nurse take?
Correct Answer: C
Rationale: The correct answer is C: Ensure the pouch is 0.32 cm (1/8 in) larger than the stoma. This is important to allow room for stoma swelling and prevent irritation.
Choice A is incorrect because rubbing the peristomal skin dry can cause skin breakdown.
Choice B is incorrect as colostomy pouches should be changed based on individual needs, not a set time frame.
Choice D is incorrect as the skin barrier should be applied to dry skin to ensure proper adhesion.
Question 3 of 5
A nurse in a mental health clinic is caring for an older adult client who has depression and has stopped taking their medication. The client tells the nurse, 'I want to die now that my partner is gone.' Which of the following responses should the nurse make?
Correct Answer: B
Rationale:
Correct Answer: B
Rationale: Asking the client directly if they have thought about harming themselves is crucial in assessing suicidal ideation. This response shows the nurse's concern for the client's safety and opens up a dialogue for further assessment and intervention.
Summary:
A: While discussing feelings with the provider is important, addressing immediate safety concerns takes precedence.
C: Inquiring about medication cessation is relevant but not as urgent as assessing suicidal thoughts.
D: Understanding the client's relationship is valuable, but safety assessment is the priority in this situation.
Question 4 of 5
To ensure client safety, a nurse manager is planning to observe a newly licensed nurse perform a straight catheterization on a client. In which of the following roles is the nurse manager functioning?
Correct Answer: C
Rationale: The correct answer is C: Client care provider. The nurse manager is functioning in the role of overseeing and supervising the newly licensed nurse as they perform a straight catheterization on a client to ensure proper technique and client safety. As a client care provider, the nurse manager is responsible for ensuring that the client receives safe and effective care.
Explanation for the other choices:
A: Client educator - This role involves providing information and teaching clients about their health conditions or treatments. The nurse manager in this scenario is not directly educating the client.
B: Client advocate - This role involves speaking up for the client's best interests. While important, it is not the primary role being demonstrated in this scenario.
D: Case manager - This role involves coordinating care and services for clients across different healthcare settings. The nurse manager in this scenario is focused on direct observation and supervision of a procedure, rather than overall care coordination.
Question 5 of 5
A nurse is planning care for a client who has acute pain as a result of a pressure injury to the sacrum. Which of the following nonpharmacological interventions should the nurse include in the plan?
Correct Answer: D
Rationale: The correct answer is D: Offer to play music in the client's room. Music therapy has been shown to be an effective nonpharmacological intervention for managing pain. Music can help distract the client from pain, promote relaxation, and reduce anxiety. It can also improve the client's mood and overall well-being. Loosening bed linens (
A) may provide comfort but does not directly address pain management. Massaging the sacrum (
B) can potentially worsen the pressure injury. Bright lights (
C) may increase discomfort for a client in pain.
Therefore, offering music therapy is the most appropriate intervention in this scenario.